Water Royd Nursing 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 good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 72 (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. Accidents and incidents were monitored by the management team, and action taken to mitigate risks to people. A clinical risk meeting was held every week, which included an analysis of incidents and any lessons learned actions. For example, some further staff training was provided following an incident. Lessons learned were discussed with staff via team meetings.

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. People received assessments prior to living at the service. Where required, information could easily be shared between services. People had hospital passports in place, which shared key details about their needs, should they require a stay in hospital.

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. Staff were trained and understood their roles, to recognise and report poor practice. Staff told us they felt comfortable to report concerns and had confidence the management team would take action. Notifiable incidents were reported to external agencies where required and safeguarding concerns were discussed with staff. People told us they felt safe, a relative said, “It is a brilliant place, just brilliant.”

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). The service was working within the principles of the MCA, and where required appropriate legal authorisations were in place.

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. Risk posed to people were assessed and mitigated. People had detailed risk assessments and associated care plans in place. People received their food and fluids in line with their assessed needs, such as modified diets to reduce risks of choking. Where people were at risk of malnutrition, snacking and fluid stations were in place, to encourage them to eat and drink. People had their weights and observations monitored. Monitoring and equipment was in place, to manage risk of falls and pressure damage to people, such as specialised mattresses, sensor mats and bed rails. A professional told us, “[Name] had pressure wounds when they moved in here, and now they are much better since living here (and receiving support).”

Improvements were required to the décor within the home. Several areas were in need of redecoration, new flooring and furniture. The provider had recognised this and had commenced refurbishments in some areas. An ongoing refurbishment plan was in place. 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 maintenance team completed regular checks on the environment and equipment to ensure this was safe for use. Fire safety measures were in place, including risk assessments and staff practice evacuations. Hazardous substances were safely locked away and safety measures, such as window restrictors and radiator covers were in place.

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 This included a team of care staff, nurses, domestic staff and clinical leads. The service also benefited from a 'lifestyle team' who provided people with meaningful activities and things to do each day. A staff member said, “It is amazing, I love it here. I am lucky that I want to go to work. Staff are good, we all get along. Staff are nice to people; we are like a big family. People that live here are happy and they are safe. Manager is brilliant. Never had to report any concerns, but feel able to, I can raise suggestions. There is enough staff on every day.” Staff were recruited safely, and all pre-employment checks were in place and staff were trained in a range of subjects to carry out their roles safely and effectively. New staff received an induction, shadowing opportunities and probationary meetings.

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. Policies and procedures were in place and staff understood their responsibilities to promote safe infection control practices. Staff were observed to wear personal protective equipment (PPE) appropriately and the service was clean and tidy.

Medicines were mostly managed safely, however improvements were required, to ensure medication stock checks were correctly monitored and discrepancies investigated. For example, we found several stock checks which had a discrepancy in the amounts. These had not been appropriately investigated or actioned. This was discussed with the management team, who assured us that measures would be put in place to address this. Medication administration records were completed by staff, and where people received 'as required' medicines, there were detailed protocols in place, to guide staff about how and when these should be given. Medicines were safely stored and disposed of. People told us they received their medicines as prescribed. A person said, “I have my medicines every morning and evening. I can see a Doctor if I need to.” Staff were trained and had their competencies assessed prior to administering medicines to people.