Matson House

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 changed to 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 people’s safe care and treatment.

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. There was a positive learning culture, supported by audits and action plans. Lessons were learnt to continually identify and embed good practice. Accidents and incidents were recorded, reviewed and used for learning, which was also shared with staff.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They had recently supported someone to move to the home and had made sure there was continuity of care. Staff worked collaboratively with professionals and families to provide joined-up care. One health professional told us, “Throughout the transition, staff prioritised [the persons] choices, preferences, and autonomy. They listened to [them], offered appropriate levels of control over [their] daily life, and balanced this sensitively with the structure [they] require to feel safe. The transition was managed with exceptional flexibility. Staff prepared [the persons] room to meet [their] personal needs and preferences, adapted rota arrangements at short notice to support [family contact], and responded quickly to emerging behaviours and support needs.”

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. However, we identified one concern which had not been shared with safeguarding. Despite the registered manager having a good oversight of the risk, we could not see a record to demonstrate that this had been explored in this instance. The registered manager took immediate action to resolve the situation and contacted the local authority safeguarding team. Whilst there were no changes to the action or management of risk as a result, all safeguarding concerns should be shared with the local authority before being substantiated or unsubstantiated to ensure a consistent and effective response.

People and their relatives reported feeling safe with staff who supported them. One relative said, “[My relative is] absolutely safe there. I have lots of examples. Certain incidences have been reacted to quickly. [My relative has] always been their priority.”

Easy‑read safeguarding information was readily available, which supported people to recognise unsafe care, abuse, and routes for raising concerns. Easy‑read information refers to accessible text presented in a simplified format using clear language and supportive imagery.

Staff demonstrated a strong understanding of safeguarding duties and described clear reporting processes. One staff member said, “Safeguarding is taken extremely seriously.”

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 assessments were detailed, person‑centred and current. People were involved in decisions about positive risk-taking, and staff understood individual preferences and communication needs.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care. We identified concerns relating to the environment, where the provider was not compliant with HSE (Health and Safety Executive) guidance and had therefore failed to ensure window safety at the home. This meant that people were at risk of harm from falls at height. In addition to this we also identified concerns regarding loose threshold bars which placed people at risks of trips, slips and falls, and inadequate ventilation and mould growth in the communal bathroom upstairs. We saw these concerns had been identified by the management team and escalated to the provider on a recurring basis, without timely action. Whilst the provider told us they had been liaising with the landlord and had identified longer term solution, they had failed to put in place measures to mitigate the risks in the interim period. We raised these concerns with the provider who took immediate action to make the environment safe.

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.

We observed there were sufficient staff throughout the assessment and staff were knowledgeable about people’s needs. Staff had completed training relevant for their role and had received supervisions. Rosters showed there had been a core staff team who supported people. One person said, “Lots been here ages, not many changes”. A relative said, “The continuity is excellent. We are 100% happy…We're happy with the relationship with the manager and staff. I would recommend it to other people. In fact, I have. I would have no hesitation in recommending it.”

Staff were recruited safely to the service. This included requesting and receiving references from previous employers, right-to-work documentation and Disclosure and Barring Service (DBS) checks. DBS checks are carried out to confirm whether prospective new staff had a criminal record or were barred from working with people at the time.

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.

People were supported to keep their home clean and tidy, and staff also regularly cleaned. Staff told us how they tried to prevent or control the spread of infection. One staff member said, “The home is clean. We use PPE (personal protective equipment) when cleaning…We have all signed a hand-washing declaration.” A professional told us, “I always see the staff going around cleaning things. There is clean and then there’s really clean. They are really good here.” Another professional said, “On my most recent visit I was extremely satisfied with what I observed within the Matson House setting. I had reviewed 4 [people] there and visited them in their bedrooms and living area which was person centred, clean, tidy and their dignity was maintained.”

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Weobservedthat medicines were given to peoplein a person-centred and caring way.

Care planscontained information on how residents liked to take their medicines. Protocols were in place to support the use of“when required medicines”,such as painkillers and laxatives.However,care plans for people prescribed flammable topical creams lacked a suitable risk assessment for these medicines.Staff did take steps to begin these risk assessments during our visit.

Staff did not record the administration ofthickeners;this meant we could not be assured that people’s risk of dysphagia or choking was being appropriately managed in the home.The management team were responsive to our feedback and took immediate steps to implement a recording process for thickeners.

Staff worked closely with the GP practice to resolve medicines issuesin a timely mannerand to ensurepeoplereceived medicines reviews.

Policies and procedures were in place relating to medicines and weobservedstaff following these during our visit. A system of medicines audits was in place at thehome,and we saw examples of how this audit system had been used to improve practice related to medicines.Staff completed mandatory medicines management training and annual assessments were completed to ensure they remained competent.