Silverpoint Court Residential 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. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained 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 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. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The provider recorded accidents and incidents, but we identified some incidents that required a statutory notification to the Care Quality Commission (CQC). When significant incidents happen, providers must send a formal report called a statutory notification to the CQC. This information helps the CQC keep track of safety, protect individuals using healthcare services, and step in with legal or regulatory action if needed. We have asked the provider to submit these retrospectively.

Since our last assessment, the provider had implemented more robust systems around analysis of falls and call bells which helped to identify any themes and actions to take. For example, 1 person had experienced several falls in one month and the provider had ensured a referral to the falls team had been completed.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

The provider was in the process of fully updating all care plans and risk assessments. We did identify there were some inconsistencies in people’s information. For example, 1 persons’ care plan stated they had type 1 diabetes in their nutrition and hydration care plan, but their diabetes care plan stated they had type 2 diabetes. The provider has since updated this information. We saw that they were being appropriately supported by the district nurse team for their diabetes management.

Feedback from external professionals was positive that the service worked collaboratively with partner agencies and that this had improved in recent months. One healthcare professional told us the staff at the home ensured any concerns about healthcare needs were raised quickly and staff were always helpful.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

At our last inspection, we found the provider had not always submitted statutory notifications to the CQC. Our last inspection highlighted that the provider did not always submit required statutory notifications to the CQC. At this inspection, we noted progress but found that some recent incidents and safeguarding concerns had not been reported. While these concerns were tracked in a safeguarding log, there was no clear record of appropriate reporting. The provider has since rectified this by submitting the missing notifications retrospectively.

The provider had safeguarding policies in place and staff had completed safeguarding training. Staff we spoke with knew how to identify signs of abuse and how to report concerns.

Feedback we received with regards to whether people felt safe in the home was positive, however, we received negative feedback around staffing. One relative told us, “I feel my [relative] is very safe there because they do regular checks on [relative].” Another relative told us, “I do not feel the home has enough staff.” Staff told us they did not always feel there were enough staff to safely support people. One staff member told us, “There are too many agency staff, so residents don’t know half the staff. Recently there has been a big turnover of staff and not enough staff.” The provider had recently recruited new staff which had reduced the need to use agency staff.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Relatives told us they had not always been involved with care plan reviews or had not seen their relatives care plan for some time. One relative told us, “Care plan - not really sure, not updated anything recently and there has been a lot going on with [relative]” and “I did have a call to say end of life care plan to be put in place but not happened yet, some time ago. I am only notified if they have to call an ambulance for [relative], but nothing else.”

The provider was in the process of reviewing and updating all care plans and risk assessments and those that had recently been reviewed had clear review dates and the date for next review documented. We have discussed with the provider making it clear who had been involved in the reviews and ensuring this was documented accordingly.

Feedback from staff was mostly positive around being kept informed of any changes to people’s needs. Comments included, “Yes, I am kept informed of any important health changes and involved when needed.” One staff member told us, “I feel I’m not always informed of change to care plans, including risk assessments.”

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 home is currently undergoing extensive refurbishment. The provider has ongoing plans to refurbish all areas of the home. During our onsite inspection, we saw that communal bathrooms had been replaced and some of the bedrooms had been refurbished. The ongoing works did not appear to be impacting people at Silverpoint Court, and disruption had been kept to a minimum. No concerns were raised with us about the ongoing refurbishment.

Checks relating to fire safety were up to date, such as emergency lighting and fire doors. Necessary safety certificates were in place to support safe environments in areas including gas safety and electricity checks. We found wardrobes were secured to the walls and necessary window restrictors were in place.

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

Feedback we received was consistent around concerns there were not enough staff at Silverpoint Court and concerns around the use of agency staff. Comments we received included, “A lot of agency staff there, and do not know the residents well. A lot of the regular staff left” and “My main concern there is you can press the doorbell when visiting and then can stand outside for over 10 minutes before its answered.”

During our on-site visit we observed staff at times, appeared task focused and not all staff interacted with people they were supporting. This was fed back to the provider on the day of the inspection. The provider has since recruited more staff to the home to help with consistency and reduce the need to use agency staff.

Staff received supervisions but feedback was mixed around training. Some staff felt they received sufficient training, but others told us they felt training could be better. Comments included, “I don’t think it’s that good” and "I have had my competencies completed and training for our new medication system has been really good.”

The provider had recruitment procedures in place to ensure the required checks were carried out prior to staff commencing their employment. This included enhanced Disclosure and Barring Service (DBS) checks for adults. DBS checks provide information including details about convictions and cautions held on the police national computer. The information helps employers make safer recruitment decisions.

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.

Whilst the home was showing signs of age and wear and tear, the provider had started extensive refurbishment of the home. Audits were in place and we observed the domestic team maintaining a clean environment during our onsite visit.

We reviewed training records and staff had received training in infection prevention and control (IPC) and health and safety. Staff had access to personal protective equipment (PPE), and we saw staff wearing PPE appropriately.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Referrals were made to the GP when required.

Medication was ordered and stored appropriately. People received their prescribed medicines in accordance with their needs. We did not identify any concerns around stock management and administration.

We reviewed the PRN – ‘as required’ protocols and these had recently been updated. Whilst some of the information was quite generic, the provider did make sure it was clear when the protocols had been implemented and when they were due for review.

The provider had a medications policy in place and controlled drugs were stored securely. The medication fridge temperatures were being completed daily. Staff had received training in medication administration and competencies had been reviewed. The provider had just started using an eMAR (Electronic Medication Administration Record) system and staff we spoke with found the training around this had been really thorough.