Burnt Tree Croft

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.

The service was in breach of legal regulation, in relation to providing safe care and treatment.

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.

People told us that they felt able to raise safety concerns to management. One person told us, "Yes, if I need anything I can speak to them [managers] and I feel listened to."

There was evidence of safety events being suitably investigated, and staff had good knowledge about recording of incidents, accidents, and appropriately escalating safety concerns.

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.

The service involved people and relatives during the admission process to ensure a smooth transition, with effective communication. Leaders could identify compatibility in referrals and assessed whether they could meet people’s needs prior to admission. A weekly GP round at the service supported people to receive health care, in a timely manner.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. When people were asked about the staff at the service, one person told us, “The staff are very kind, I can’t fault them.” Another person told us, “I feel safe and looked after here.” Staff could identify appropriate ways to safeguard people and understood how to promptly escalate any concerns. Staff received up to date safeguarding and mental capacity training and were involved in learning lessons from previous incidents and safeguarding matters.

The provider did not always work with people to manage risks. Staff did not always provide care to meet people’s needs that was supportive in managing and minimising behaviour that communicated a need, emotion or distress. For example, one person did not have a behaviour support plan in place, to guide staff about how to support them during incidents of distress. Staff had also failed to access external professionals, to explore why this person may be in distress. Staff lacked appropriate training, in relation to supporting people during behavioural incidents. Retrospectively, the service told us they are looking at sourcing training for staff, to proactively manage behaviour that challenges. We did find risk assessments which were person-centred, proportionate, and regularly reviewed with the person, where possible. One relative told us, “They [staff] are brilliant and ensure the safety of my [relative], they always make sure equipment is in place when [relative] needs it, and lets them do what they can for themself first.”

The provider did not always detect and control potential risks in the care environment. They did not make sure that the environment supported the delivery of safe care.

Whilst we found no harm to people, we found numerous environmental concerns. Two cupboards containing Control of Substances Hazardous to Health (COSHH) materials were left unlocked and accessible. This placed people at risk of ingesting unsafe substances. A cupboard leading to the lift mechanism was also left accessible to the people that lived at the service. There were no window restrictors on all top panel windows, and they exceeded the current Health and Safety Executive (HSE) guidance of 10cm width. This placed people at risk of falling from height. Window restrictors were retrospectively put on all top windows following the inspection and the cupboards locked.

People had red bulbs in their rooms, for the purpose of night lights. However, these were found to be very hot to touch, with no safety covering. We also found 1 light without a bulb, exposing the electrical current behind it. There was a broken communal bathroom lock, which exposed sharp metals at shoulder height and a broken tap in a communal bathroom, which also exposed sharp metals. We also found a communal bathroom without an emergency pull cord.

Due to the age of the building, we requested risk assessments in relation to Asbestos management. We received a risk assessment which was not appropriate in the safety, management and controlling of asbestos. We found no evidence that previous risk assessments had been undertaken relating to Asbestos.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff were recruited safely, with appropriate pre-employment checks taking place, this ensured staff were suitable for the role.

Appropriate staffing levels were in place, including an appropriate skills mix, to ensure people received good quality care that meets their needs. Staff told us moral was improved amongst the team when staffing was at a consistent level of regular staff on each floor. Staff received training appropriate and relevant to their role and told us they were given the support they needed to deliver safe care. This included supervision, appraisals and support to develop their skills.

The provider did not always assess or manage the risk of infection. We found people were not protected as much as possible from the risk of infection due to premises and equipment not being kept at a clean and hygienic standard. During our assessment we found mould and stained bathing facilities and equipment in communal bathrooms. Kitchen facilities such as microwaves and fridges, were visibly dirty and were left un-hygienic. Food contents in communal fridges were not labelled with expiry dates. We found heavily stained chairs and tables in communal dining areas. Cleaning schedules evidenced gaps in cleans taking place, and we could not be assured any deep cleans were being carried out to ensure the premises and equipment were maintained effectively to help prevent the spread of infections.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We found that people were put at significant risk of harm as medicines had not been managed effectively. People had often not received their medications as prescribed due to being asleep at the time of administration. No advice was sought from medical professionals when this pattern had lasted over a significant number of days. One person who was administered Warfarin, did not have a care plan or risk assessment in place, to guide staff about how to safely manage this medication. Opened and expired eyedrops were being used for one person, and systems to ensure medicines were administered safely had not identified this concern. Protocols for ‘as required’ medicines did not always guide staff about how they should assess individual people’s need for the medicines prescribed as required. This meant people may not have been given their medicines at the times they needed them. Where ‘as required’ medicines were administered, there was a lack of records about amounts given, the reasons for administering, the time of administration for time sensitive medicines and the outcome of whether the medicine was effective. Warnings in relation to one person’s medication was not included in their Medication Administration Record (MAR) Meaning we could not be assured risks posed to this person were effectively managed.