Conifers 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 requires improvement. At this assessment the rating has changed to 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.

There was 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.

The management team had developed mechanisms to ensure staff took learning from past events at the service. Information was shared amongst leaders, heads of departments and staff to ensure people’s information was up to date and relevant.

When people’s needs changed, records were updated to reflect the changes ensuring staff were able to provide safe and effective care.

There was a more open and transparent culture, where staff felt safe to acknowledge when mistakes occurred. The emphasis was placed on learning from these events and implementing meaningful actions to prevent recurrence.

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.

Pre-admission assessments were completed, and when individuals transitioned to other services, relevant information was consistently shared with the receiving teams to support safe and informed care planning and improved outcomes for people.

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. The provider shared concerns quickly and appropriately.

Staff had received safeguarding training and were able to demonstrate their understanding of safeguarding principles and responsibilities. A staff member said, “We do safeguarding training, and I had this recently. I would report concerns to my senior and then the nurse and even CQC.”

However, one member of staff told us they were unsure about the home’s whistleblowing policy. We discussed this with the manager who told us they would schedule this for follow-up and reiterate the policy with all staff.

Safeguarding referrals were made appropriately when concerns arose, and the service demonstrated a commitment to learning from incidents, with actions taken to improve practice and prevent recurrence.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. This can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that mental capacity assessments were in place, and the provider was meeting their obligations in relation to DoLS.

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 management was much improved. People were supported to engage in positive risk-taking, promoting autonomy and choice. For example, the management team had supported one person to take positive risks by ensuring they had lots of information about the choices they were making so the person was able to stay safe whilst ensuring they were able to do as they wished.

Where individuals had specific risk-related needs, detailed assessments were completed, and care plans were completed accordingly. These plans included detailed information relevant to individual health conditions, such as diabetes and epilepsy ensuring that care was both person-centred and tailored to each person’s condition and daily support needs.

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 equipment and premises were safe and well maintained.

Individuals had access to their own personal equipment, such as slings, which were used exclusively to meet their specific needs and promote dignity and safety.

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.

Staffing levels had become more consistent which had contributed to improved morale across the staff team. However, all staff members reported that additional staffing would strengthen the support available to people. One staff member said, “Some days we are short of staff. Management will try to get agency, but not always possible. Our own staff usually cover though, and we work well as a team.”

The manager used a dependency tool to assess the level of support required and had agreed to review the dependency tool based on the information staff had provided.

Staff training compliance had improved. However, some staff had gaps in their training, with certain modules not updated for some time. The management team were advised to ensure that all expired training was promptly updated to maintain compliance and best practice, and this was followed up with staff.

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.

The home was visibly clean, tidy, and well maintained, creating a pleasant and hygienic environment for people living there. Staff were observed following infection prevention and control procedures, including the correct use of personal protective equipment (PPE), in line with current guidance.

Cleaning schedules were in place and regularly audited to ensure standards were upheld.

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.

Systems and processes had significantly improved since the last inspection.

During the visit, a gap was identified on a body map relating to patch rotation. While no harm had occurred, the issue highlighted the need for improved communication between nursing staff and management. Nursing staff discussed the concern on the day and agreed to adjust their practices to help prevent similar issues occurring in future.

Regular audits were being carried out, which had been effective in identifying areas for improvement and supporting ongoing improvements across the service.