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 continued to be in breach of legal regulation in relation to the way people’s medicines were managed.

This service scored 62 (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.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 assess 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. 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 worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. The provider had made improvements in how risks were managed and was in the process of sourcing training to support staff in responding to behaviour that challenges. Risk assessments were person-centred, proportionate, and regularly reviewed with individuals where possible. The service had engaged external professionals to better understand and respond to behavioural distress.

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 provider had taken action to address previously identified environmental risks and had made improvements to ensure the environment supported the delivery of safe care.

The provider had taken steps to improve the management of asbestos. A new asbestos risk assessment had been completed, and appropriate measures were in place to monitor and manage associated risks in line with health and safety requirements.

However, some minor environmental issues were identified during the inspection, but the provider took prompt and appropriate action to address these.

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 morale improved amongst the team when staffing was at a consistent and regular level 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 assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. At the previous inspection, the provider did not always assess or manage the risk of infection effectively.

At this visit, we found the provider had taken effective action to manage the risk of infection. The environment was visibly cleaner, and equipment and premises were maintained to a hygienic standard. Cleaning schedules had improved, and staff were following appropriate infection prevention and control procedures. While some minor IPC issues were identified, these were addressed promptly during the inspection.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. At the previous inspection, we found significant shortfalls in the safe management of medicines. At this inspection, some improvements had been made. Protocols for ‘as required’ (PRN) medicines had improved in several cases, providing clearer guidance to staff on when and how to administer these medicines. However, some PRN protocols were not in place. We continued to find concerns in the recording and administration of medicines. Records relating to transdermal patch application and rotation were incomplete, meaning it was not always clear whether patches were applied correctly or rotated in line with clinical guidance to reduce the risk of skin irritation or overdose. Further improvements were required in the safe storage, disposal, and temperature monitoring of medicines. The medicines room was not consistently maintained within the recommended temperature range, and there were gaps in the records of medicines returned or disposed of, which meant we could not be assured that medicines were managed safely and in line with current guidance.