Cotleigh

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 remained good. This meant people were safe and protected from avoidable harm.

This service scored 69 (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. Accidents and incidents were appropriately recorded and monitored. Accidents and incidents were discussed by the senior management team during weekly governance meetings. Lessons were learned from incidents and were discussed with staff during daily handovers and team meetings. Staff understood their roles and responsibilities to record and report accidents and incidents.

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. Care records were electronic and could be easily shared between services, where appropriate. Visiting professionals told us staff worked well with them and acted upon their advice. A professional said, “I come and do a ward round every week. People are well cared for. I have a good working relationship with the staff and the home is very well run.” Where people required a stay in hospital, information packs were available, to give hospital staff information about their needs.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. People told us they felt safe. A person said, “I feel safe here. Staff know me well and treat us like part of the family.” 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. Staff were trained about how to spot signs of abuse and told us they felt comfortable to whistle blow on poor practice. A staff member said, “I have never had to report any safeguarding concerns. People are safe. Any issues I will raise them. I could go to manager if needed, they are good, very approachable.” The provider shared concerns quickly and appropriately.

The provider did not always detect and control potential risks in the care environment. They did not make sure equipment, facilities and technology supported the delivery of safe care. Whilst we found most environmental safety measures were in place, such as equipment checks and maintenance works, we found some environmental risks. A recent fire department visit had flagged some areas of concern, we found most of these works had been completed, however the fire safety risk assessment was not robust, and the fire service had requested this be completed by a competent person. Staff were trained in relation to fire safety and people had personal evacuation protocols (PEEP’s) in place. We also found some unlocked cupboards containing hazardous substances. Action was taken immediately to rectify this, and the manager told us they planned to introduce daily checks.

The provider did not always detect and control potential risks in the care environment. They did not make sure equipment, facilities and technology supported the delivery of safe care. Whilst we found most environmental safety measures were in place, such as equipment checks and maintenance works, we found some environmental risks. A recent fire department visit had flagged some areas of concern, we found most of these works had been completed, however the fire safety risk assessment was not robust, and the fire service had requested this be completed by a competent person. Staff were trained in relation to fire safety and people had personal evacuation protocols (PEEP’s) in place. We also found some unlocked cupboards containing hazardous substances. Action was taken immediately to rectify this, and the manager told us they planned to introduce daily checks.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. A staff member said, “Staff are very kind, people are safe. We have good staff. It is a lovely place.” Staff were trained in a range of subjects, including dementia, first aid and positive behaviour support. The provider had also recently introduced further best practice training modules. People and staff told us there was enough staff and we observed people having their needs met. A relative said, “The staff respond to [name] call bell promptly and provide the best care.” Staff were recruited safely, and all appropriate pre-employment checks were in place, this included regularly updated police records checks.

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. Most of the service was found to be clean and tidy. However, we found some kitchenette areas required cleaning. A relative said, “The home is so lovely. Clean, bright, cheerful, decoration is so good.” Infection, prevention and control audits had identified some equipment which was required to store Personal Protective Equipment (PPE), and these had been ordered. There were clear infection control policies and procedures, and staff were trained and observed wearing PPE as required. New dishwashers and handwashing facilities were also being fitted at the time of our assessment. The manager had requested an external Infection, Prevention and Control (IPC) visit, to enable them to improve upon their infection control practices.

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. A relative said, “I know [name] gets their medication. [Name] and I know what they’re taking.” Staff were trained and had their competencies assessed prior to administering medicines to people. Medicines Administration Records (MAR) charts were completed and where people received 'as required' medicines, protocols were in place to guide staff about how and when to administer these. Audits were undertaken to ensure people were receiving their medicines as prescribed.