Gracefields 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 at 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.

The safety of people was monitored through an adverse‑events tracker, which staff completed after any accident, fall or safeguarding concern. They recorded what they thought had caused the event, and after investigation, added the confirmed cause, contributing factors and actions taken to stop it happening again. Falls had reduced compared with the previous year, and staff had completed extra training and supervision. However, some records were incomplete because different systems overlapped. The provider had identified this and started to implement new systems to improve oversight.

Staff used 24‑hour reports during handovers to reflect on what had happened and why, helping them learn from safety issues. Training on syringe drivers was refreshed after a safeguarding concern, showing the service acted when concerns were identified.

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 were supported through safe and well‑organised systems that helped staff work with other professionals to maintain consistent care, including when people moved between services. When people moved into the service, pre‑admission assessments were completed with relatives involved, helping staff understand people’s needs and life history. People could bring personal items to make the transition easier. Staff made referrals to other professionals when needed, such as physiotherapists who assessed mobility on arrival.

When people moved out of the service, discharge plans included all the key information needed to support a safe transition. These plans set out the person’s health needs, allergies, infections, treatments, medical history, risks and any follow‑up required. A full list of medicines, the MAR chart, clothing records and a body map were included to make sure nothing important was missed. Each plan was signed and dated, helping ensure continuity of care and clear communication between services.

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 completed safeguarding training which helped ensure they understood how to keep people safe. Professionals we spoke to said staff were confident and took timely action when raising concerns and knew who to speak to if they were worried about someone’s wellbeing. One health professional said, "Safeguardings are always raised in a timely and appropriate manner”. The service reported concerns when needed. Safeguarding was led by the manager supported by the wider provider team to oversee any concerns and make sure appropriate actions were taken.

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 (MCA). In care homes, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). When we looked at the records for these, they were reviewed and up to date. The Deprivation of Liberty Safeguards in place for one person helped ensure they could continue living in a way that reflected their preferences. For example, staff supported them to go outside by making sure they were dressed appropriately, and their family had shared that spending time outdoors was especially important to them.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

There was no system in place to check whether people’s mattress settings were at the right setting for their weight, which put them at potential risk of pressure damage. A new blood glucose device had been introduced, however, there was no clear guidance in people’s care plans about how this should be used to safely support them. Some care plans lacked key information. For example, one person self‑managed their colostomy, but there was no guidance for staff on supplies, skin care or equipment if they needed support in future. Pressure‑ulcer treatment was in place, but repositioning records varied, so staff did not always have a consistent picture of how often people were being repositioned. Some policies, including catheter care, were updated during our visit to provide clearer instructions for staff.

At the time of our inspection, some personal emergency evacuation plans were not up to date. However, when this was highlighted, the service updated them promptly. This meant staff had the correct information to support people safely in an emergency.

People’s nutrition and weight were monitored regularly so that any changes could be picked up early and the right support put in place. Risks linked to people’s health needs were clearly recorded in their care plans, including safe use of emollient creams and important fire‑safety information.

Staff supported people to take positive risks that helped them stay independent and enjoy meaningful experiences. We heard examples where staff encouraged a person who was learning to use a new motorised wheelchair to practise moving around safely, which helped him become more confident and happier. Another person was supported to help with small tasks at lunchtime because staff recognised this made him feel calmer and more settled.

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 provider maintained the building and ensured equipment was safe. The manager checked the service every day to make sure there were no hazards, and any problems were recorded and addressed. Fire safety checks, gas and electrical tests, and water safety checks were all up to date, and recent assessments showed no concerns. Cleaning products were stored securely, and the provider completed internal safety audits.

The service had two floors with lifts and stairs that were kept secure with keypad access. There was a garden patio area that people could use safely when supported by staff, which was close to the nurses’ office, so staff could safely monitor people. Equipment such as lifts and hoists had been safety checked and were in good condition, and the service had valid insurance in place.

Fire alarms, emergency lights and extinguishers were tested regularly, and staff had taken part in a fire drill. The provider also planned for risks linked to bad weather, like flooding, and made sure the environment stayed safe for both people living at the service and the staff working there.

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.

The provider ensured systems for assessing people’s needs were effective, with dependency tools kept up to date and accurate so staffing levels could be maintained even when people’s needs changed. Agency staff worked alongside permanent staff when required, although they did not provide 1:1 support. While most feedback about staffing was positive, some people raised concerns about staffing levels overnight.

Recruitment processes were in place, and all records we reviewed were up to date and accurate. A Disclosure and Barring Service (DBS) check confirms whether a person is suitable to work with vulnerable people. Work was underway to implement a new policy for DBS renewal, which required staff to sign an agreement confirming they would inform the service if their DBS status changed.

Staff supervisions took place, but their impact varied. For example, even after supervision about repositioning, inconsistent practice was still occurring.

The staff training matrix set out the modules staff were expected to complete. A new training system was in development to cover aspects of the Care Certificate, the national induction standards for care staff in England. The additional content was designed to support the individual needs of residents and staff, including a focus on personal professional development. Group supervisions were held in response to new issues or to support continuous learning, such as supporting people with dysphagia.

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 environment was clean and well maintained. Both floors were clean, tidy and well organised. Cleaning products were stored safely, cupboards were well arranged and staff were confident in how to use personal protective equipment safely. Visiting professionals commented that the service was very clean, and one highlighted that they valued the use of individual slings for each person. However, we identified slight malodours on one floor of the home.

During the inspection, we saw that open‑top bins were being used. Open-top bins increase the risk of spread of infection. The provider acted straight away and replacement bins were purchased. Daily cleaning records were completed and checked weekly by the manager to make sure standards were maintained. The food hygiene audit was up to date with any actions needed clearly planned.

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.

Protocols for medicines people needed ‘as required’ was inconsistent, with no specific instructions for medicines such as morphine or paracetamol. There was no pain‑assessment tool in use to support staff to know when people might require pain relief. Staff relied on their knowledge of residents, although there was evidence of analgesia being administered and recorded appropriately.

Medicines were not always stored in line with the providers policy. Refrigerated medicines were kept within the correct temperature range, and stock audits and covert‑medicine agreements were completed appropriately. However, room‑temperature medicines were sometimes stored in unsuitable areas with limited space. The service agreed to relocate this storage to a more appropriate room. Medicines no longer required were safely stored.

Care plans lacked detailed instructions in relation to people’s medicines, and gaps in recording meant important information was not always captured. People told us they received their medicines but written guidance for staff did not always support consistent practice. Other aspects of medicines management were safe, but medicines and treatments were not always managed in a way that ensured safety or reflected people’s preferences.