Tolson Grange

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 the ways people’s medicines were managed.

This service scored 59 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice.

There were some missed opportunities in the approach to learning lessons. Accident and incident monitoring was not always used effectively to learn lessons and drive improvement. Accident and incident forms were completed, and a root cause analysis was undertaken by the registered manager to determine why the event occurred; however, the learning outcomes from the incident were not recorded.

Reflective practice sessions were used for staff to help their learning when issues were identified. Additionally, the provider had a system in place for staff across their services to learn from events in individual services.

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.

Systems were in place to make sure people’s needs were assessed to make sure they could be accommodated safely prior to being offered a place at the service. Assessments were completed by either the registered or deputy manager and information gathered during the assessment was used to develop initial care plans.

Hospital packs had been developed for if people needed to be admitted to hospital. These packs helped medical staff understand the person, their needs and the support they need to meet them.

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 understood their responsibilities in maintaining people’s safety. They received training and had access to information to enable them to contact the local safeguarding team independently if the need arose.

All the people we spoke with felt they or their relative were safe. One person said, “I feel very safe here” and a relative told us, “Yes, [person’s] safe and seems quite happy.”

The Mental Capacity Act 2005 (MCA) outlines how decisions should be made for individuals lacking capacity. MCA principles were consistently followed with capacity assessments completed, and correct procedures followed in relation to making best interest decisions where people lacked capacity to make informed decisions about their care. Systems were in place to make sure where people lacked capacity, the principles of the MCA were followed. Capacity assessments were completed as needed and, where people lacked capacity, best interest assessments were completed appropriately.

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 and supportive.

Risks to people’s health and wellbeing were not always assessed as thoroughly as needed to make sure people were safe. Some people had risk assessments and care plans in place to support having their bedroom doors locked whilst in their rooms. However, we found one person in a state of upset, banging on their door and shouting they could not get out. The person’s care plan stated they may forget to use their call bell but said they had a sensor mat in place to alert staff when they were walking about. A sensor mat had not triggered the call system, and no staff were available on the unit to hear the person calling out. The person’s risk assessment, and ones for other people with a locked door had not considered if the person was able to unlock the door from the inside.

The provider took immediate action to make sure people were safe including ordering single action door handles which meant the door would automatically unlock when the person used the door handle.

One person’s records detailed how, due to confusion, they feared for their own safety and had been found misusing sharp objects to damage their property. This was not reported during handover, and an incident report had not been completed which meant the registered manager was unaware of the incident. A reflective practice was put in place immediately to address this.

Staff told us they did not always read people’s risk assessments. This was being addressed by the management team.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Systems were in place to make sure people lived in a safe environment. Compliance checks to ensure the safety of the building and environment were up to date. Fire safety was promoted through an up to date risk assessment, staff training and documents known as PEEPs [Personal emergency evacuation plans] developed and reviewed regularly to support safe evacuation of people in the event of an emergency.

Environmental safety audits were completed and the call bell system and assistive technology used, such as motion and bed sensors, were reviewed weekly by maintenance staff to make sure they were working correctly.

The provider did not always make sure there were enough qualified, skilled and experienced staff. Staff did not always work together well to provide safe care that met people’s individual needs.

Staff were recruited safely and followed a comprehensive training programme. The provider was aware that some work was needed to make sure the induction process for new staff was properly followed and documented.

Staff did not always work in line with their training. For example, we observed 2 members of staff trying to support a person with using their walking aid. The direction they were giving the person was incorrect and causing the person discomfort. A third member of staff intervened and supported the person appropriately. Managers addressed this issue immediately.

Staff told us they did not have time to support people to engage in meaningful activities. Although this was not evident during the assessment, 1 staff member said they thought attention to detail with aspects of personal care, such as hair care, was affected by staff having to rush. We observed occasions when there were no staff present, or when the only staff member available in the lounge and dining area was a newly recruited employee who should have been shadowing a more experienced colleague. The provider took immediate action to address a concern we identified to make sure there were enough staff available to people, in all areas of the service, to make sure their needs were met.

During one of our visits, we observed that a member of care staff had been redeployed to the kitchen to cover staff absence, with an agency carer brought in to provide care. This did not support continuity of care. We raised this with the management team and questioned why agency staff had not been utilised to cover the kitchen role. The management team assured us they would address this.

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 service was clean and nicely presented throughout. Personal protective equipment such as gloves and aprons were available and we saw staff used these appropriately.

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

There were systems in place to make sure medicines that needed to be given at specific times were given safely at the correct times and any allergies people had to medicines were properly recorded. There was also a system in place to make sure people were not given medicines which they were allergic to. However, medicines overall were not managed safely.

People did not always have their medicine administered as prescribed. One person was given a double dose of their medicine which was discovered by the inspector despite staff stating the records had all been checked for any errors made by agency staff who had administered medicines the previous night.

One person missed having a dose of their medicines because it was out of stock and had not been ordered in a timely manner. If people miss doses or are given too much medicine their health is placed at risk of harm.

There were discrepancies between the quantity of medicines held within the service and the recorded stock levels. As a result, it was not possible to determine whether medicines could be fully accounted for or if they had been administered safely. The records about the application of creams could not always show that they had been applied as prescribed.

There was a system in place to ensure people could manage their own medicines if they wanted to. However, there were no checks in place to make sure people were managing their own medicines safely. There was no system in place to ensure people were safe when they bought or ordered their own over the counter medicines or if they stored them safely.

When people were prescribed medicines to be taken ‘when required’ or with a choice of dose, protocols were in place to support their administration. However, some of the protocols were not detailed enough or they contained incorrect information. This meant staff did not always have clear guidance to ensure medicines prescribed in this way could be administered safely and consistently as prescribed.

Some people needed to be given their medicines covertly, by hiding the medicines in food or drinks. There were a number of documents that listed the medicines which could be given covertly but the lists did not match. Information from a healthcare professional about how to give covert medicines safely was not always available. Staff confirmed they gave all medicines in a single drink rather than following good practice of giving each medicine individually and that no advice had been taken to check it was safe to do so.

When people were prescribed a transdermal patch there was a system in place to record the site the patch had been applied to. However, staff did not make a record of the sites they had used which meant it was not possible to determine where to apply subsequent patches safely, placing people at risk of skin irritation or the medicine not being absorbed from the patch safely,

Medicines were not always stored safely including the storage of waste medicines which did not follow current guidance for safe storage. Medicines requiring cold storage in a fridge had not been stored safely. The records showed that the fridge temperatures had been out of range for or over 6 months which meant any medicines stored in the fridge during that time may not have been fully effective. A new fridge was delivered during the assessment.

We found no evidence that people were harmed at the time of the assessment because the harm is not always immediate. However, people were placed at increased risk of harm by not managing medicines safely.