The Cyder Barn

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 risk management.

This service scored 59 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice. There was a process in place to record accidents and incidents, with audits of falls completed monthly. However, we were not assured that this process ensured effective analysis of accidents and incidents, meaning opportunities to minimise the potential risk to people from future accidents and incidents may have been missed. For example, falls were being quantified however records did not indicate these had been analysed for all possible trends. We discussed this with the registered manager who told us they would ensure all possible trends would be analysed.

Staff told us they had learning culture. One staff member told us, “It is always discussed in meetings.” The registered manager told us, “At staff meetings and supervisions we sit down together and look at what went wrong, how we can change things or approach things differently.” The registered manager also told us about their learning from a recent complaint and how practice had been changed in response to this.

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. Records of individuals' care needs were maintained for sharing with other professionals when necessary. A process was in place to ensure relevant information was communicated when individuals were admitted to hospital. A professional told us that needs or requests identified during assessments were considered and addressed. Another professional told us staff liaised with them to help contribute to safe transitions.

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 looked comfortable and relaxed with staff who supported them. People told us they felt safe living at The Cyder Barn. One person told us, “I feel really safe.” Staff understood their responsibility to report abuse and neglect and felt confident to do this. One staff member told us, “If I suspected abuse I would go to management and whistleblow in private, they would absolutely take action, if not I would go to CQC, they promote that here.” Another staff member told us about a safeguarding concern they had raised which had been addressed by the registered manager. The registered manager told us appropriate applications were completed to authorise a person being deprived of their liberty.

The provider did not always work well with people to manage risks. Whilst people had risk assessments in place covering key areas such as falls, moving and handling, skin damage, malnutrition and Emergency Evacuation Plans (PEEPS), some lacked sufficient detail to guide staff in supporting specific health conditions. We did not find these shortfalls had impacted on people's care as staff knew people well, and the concerns identified were rectified during the assessment.

During the inspection we observed 1 person not being supported in line with their moving and handling care plan. We discussed this with the registered manager who provided assurances this would be addressed.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology consistently supported the delivery of safe care.The service had a system for environmental checks; however gaps were identified in this.

We identified some radiators had exposed piping which could potentially cause a risk of burns if a person fell against them and the radiator was on. A risk assessment was put in place during the assessment and lagging was applied to exposed pipes.

There were a number of checks completed by external contractors. Issues found during these checks were not always acted upon in a timely way. For example, actions from a fire door survey and a compartmentation survey in 2022 had not been completed. Fire risk assessments completed in October 2022 and February 2024 found a number of shortfalls. The provider failed to rectify all of these shortfalls within the required timeframes. This placed people at risk. We contacted the local fire service regarding our concerns.

The action plan from a health and safety site visit completed in December 2024 states the hot taps in 9 basins in residents’ rooms is over 50 degrees and work will be completed by 30 June 2025. The service completed weekly water temperature checks. At the time of the site visit, records detailed that some were still found to be above the recommended safe temperature. This was addressed during the assessment.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. We received mixed feedback from staff regarding the frequency and quality of the supervisions they received, and although staff told us they received regular training, records did not evidence this.At the time of the assessment the registered manager was putting a process in place to address the concerns and assure themselves staff received training and supervision in line with the providers policy.

Dependency tools were used to calculate staffing levels. Most people felt there was enough staff to meet their needs. However, 1 person told us, “I sometimes have to wait a while when I ring the bell.” A relative also told us, “Sometimes there are not enough staff, but I have found that there are more now than recently.” The registered manager had recently started to audit call bells, and was aware some people were waiting for bells to be answered. They were monitoring this and provided assurances that action would be taken.

People were cared for by staff who had been safely recruited and staff told us they had opportunities to develop and achieve relevant vocational qualifications. One staff member told us they were supported to complete their NVQ 3, and another member told us they had just started this. The registered manager told us they had started a programme of completing appraisals with staff. One staff member told us it was the “Best appraisal I have had in years.”

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. All areas of the home were observed to be clean. Staff had access to the necessary personal protective equipment (PPE) and were seen wearing it throughout our visits. One relative told us the cleanliness of the home was “Spot on.”

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. Medicines were generally administered as prescribed. There was an overarching medicines policy available and monthly audits were completed. Staff received training and storage of medicines were appropriate and secure. The service used a paper-based medication administration record (MAR) system and electronic care planning system. There were some gaps in MAR availability and recording. For example, 1 persons medication was being recorded in a manager’s notebook and not on a MAR. Risk assessment (for example, for anticoagulants and self-medication) were mostly in place and fire risk assessments for flammable emollients were seen. PRN protocols were generally present and in date. However, in some cases, PRN medications were administered without confirming need.