South Chowdene

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 the last inspection we rated this key question good. At this inspection the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. The new registered manager ensured lessons were learnt to continually identify and embed good practice. The management team used information from incidents and complaints to inform supervision and improve practice. Accidents and safeguarding alerts were recorded and reviewed to identify lessons. Staff told us they felt supported and were encouraged to raise concerns. One staff member said, “If I have any concerns, I raise them immediately and make sure they are dealt with.” Another added, “Lessons learned are shared in meetings and supervisions, so everyone knows what went wrong and how to fix it.”

Staff worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. People experienced safe and well-managed transitions between services. Staff worked collaboratively with healthcare professionals to ensure changes in people’s conditions were addressed promptly and safely. Care records were person-centred and supported continuity of care, although some were not always captured in electronic records. When this was raised, the registered manager acted immediately to ensure all known risks were documented. A visiting professional commented, “Staff are very knowledgeable about the people within the home.” Another professional noted, “In recent months we have seen a significant improvement in communication during GP ward rounds, which has resulted in safer and more effective care.”

Staff worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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 service had effective systems to identify and respond to safeguarding concerns. People told us they felt safe, and staff understood safeguarding responsibilities. Staff described feeling confident to speak up: “I have raised concerns when needed because I am open and transparent and yes, they were dealt with very promptly.” Records showed safeguarding processes were clear and effective.

Although staff aimed to provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them, feedback indicated this was inconsistent. Staff understood risks posed for people, however these were not always captured in the electronic care records. One staff member explained, “We discuss likes and dislikes with residents and families and involve them in risk planning.” When we raised this, the registered manager took immediate action to ensure all known risks were recorded in the records.

The provider had detected and controlled potential risks in the care environment. The service supported people to live in safe and comfortable environments. They made sure equipment, facilities and technology supported the delivery of safe care and worked with external professionals to review people’s aides. People were supported to be as independent as possible within the environment. The staff team knew who to contact when people might benefit from additional aids or equipment. Staff were trained to use any equipment people needed.

The provider did not always make sure there were enough qualified, skilled and experienced staff. Feedback consistently outlined concerns about low staffing levels, which led to people being unobserved in communal areas, pressure on staff and the lack of time to provide all the care needed. One staff member said, “There are not enough staff and time to complete our roles.” Another added, “On particularly busy days, it can be challenging to give residents the full attention they deserve.” The service routinely provides care and support to large numbers of people receiving end of life care and so the needs within the home can change rapidly. The dependency tool did not fully account for fluctuating needs, such as end-of-life care. There is 1 nurse on duty per shift, and the deputy manager works most of their shifts as the nurse so had little time to oversee the service, which all added additional pressure on the team. We found a review of staffing levels was needed. Since coming into post the registered manager had stabilised the staff team, filled staff vacancies and reduced the use of agency staff. They were committed to ensuring staff could meet people's needs at all times.

Overall recruitment practices were meeting requirements; however the recruitment team were not always ensuring staff were providing a full employment history. Agency staff profiles did not always record people’s right to work; a photograph or the dates they completed training. The registered manager took immediate action to address these gaps. The management team made sure staff received effective support, supervision and development.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Staff adhered to infection control protocols, including appropriate use of PPE and regular audits. An infection control champion carried out daily checks and liaised with management during outbreaks. Domestic teams completed frequent touch-point cleaning, and staff received annual IPC training and refreshers.

Staff had not always made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Concerns with medication administration records (MAR) were noted including gaps in MAR charts, unclear codes, and discrepancies in stock counts. A visiting professional said, “Controlled drugs cupboard locked correctly, nurse had keys, all meds correct,” but also highlighted, “Handwriting needs improving as difficult to read.” The registered manager took immediate action to resolve these issues. They ensured staff who administered medicines completed additional competency checks and supervisions in respect of medicine management.