Surbitonian Gardens at Poppy Court

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 Good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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 encouraged a culture where staff discussed and learnt from things that went wrong. Staff reported and recorded accidents, incidents and concerns. These were individually recorded on the provider’s system and investigated in accordance with the provider’s incident management policy and procedure. Action was taken as required to keep people safe and improve the service and these were also recorded. Lessons learned were disseminated to staff and discussed during group supervision meetings.

The provider supported people to have safe transitions and pathways. The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed and monitored as needed. The provider ensured continuity of care, including when people moved between different services. People’s care records included information from other professionals to ensure care was joined up.

The manager confirmed they worked with other partners to ensure there was continuity in the management of people’s care. There were established systems in place for admission to or discharge from hospital. We reviewed a sample of records and saw that where people were coming into the home from hospital, there was clear handover information provided which was incorporated into people’s care plans as required.

The provider had clear systems and processes in place to minimise the risk of abuse. People told us they felt safe at the service and with care workers. People and their relatives told us they felt safe at the service and in the company of staff.

We conducted this assessment due to concerns about a particular safeguarding concern. We found the provider had conducted appropriate investigations into the matter in line with their policy and had taken appropriate action to minimise ongoing risk to people.

Staff received safeguarding training on an annual basis and had a good understanding of safeguarding procedures and knew what to do if they had any concerns about people. One care worker told us, “People are treated well. If I had any concerns, I would report it.”

The provider shared concerns with other organisations as required. There were clear safeguarding and whistle blowing procedures in place and the manager confirmed they were aware of when to report concerns.

The provider worked with people to understand and manage risks to their health and safety. The provider developed personalised risk assessments covering different areas of people’s health and safety. These were reviewed on a monthly basis and were updated in accordance with people’s changing needs. We saw some people had significant risks to their health and this included skin integrity issues as well as mobility issues. We saw the provider conducted daily monitoring and kept people’s notes up to date so changes in their needs were identified quickly. Where daily checks were required, for example with people’s skin integrity, we saw these were completed and recorded within the person’s electronic daily notes. Where new risks were identified, prompt action was taken to manage these, for example, through contacting multi- disciplinary professionals for extra support.

Staff understood the risks to people’s care and gave us examples of individual people they provided care to and what their needs were. For example, one care worker told us about the specific health concerns about a person they were caring for when we questioned them.

The provider detected and controlled potential risks to people’s environment. They made sure equipment, facilities and technology supported the delivery of safe care. People had individual care plans relating to the maintenance of a safe environment and this included specific personalised actions that staff were required to take to ensure people were safe in their environments. For example, one person’s care plan had an action for staff to complete regular environmental safety checks to ensure there were no hazards the person could trip on or that their equipment appeared safe for use.

The provider conducted a comprehensive environmental risk assessment to ensure the building was safe for people. Equipment was checked externally to ensure there were no issues and if issues were identified, we were told these would be dealt with. For example, we saw a recent risk assessment relating to people’s hoists and slings and these did not identify any concerns.

The provider made sure there were enough qualified, skilled and experienced staff in place to support people. The provider carried out pre- employment checks on staff to ensure they were safe to work with people and provided a comprehensive induction, which included training and a period of shadowing of other staff.

The provider ensured staff received ongoing support, supervision and development to ensure they remained able to provide safe care that met people’s individual needs. Supervisions were conducted quarterly and additional small group supervisions were carried out to discuss specific topics that were relevant to people’s roles.

As far as the supervisions go, everyone has had this. The spreadsheets are not clear on the start and end dates of supervisions. Everyone has had a supervision as needed as confirmed by staff.

The provider conducted comprehensive annual appraisals to ensure staff were performing well and received the support they needed. Staff told us they found these useful and felt they had the support they needed. For example, one care worker told us “I have been getting supervisions and appraisals- they are useful and it’s a good chance to think about and talk about how things are going. I feel well supported here.”

Staff told us they felt there were enough of them scheduled to work on shift to support people. People gave mixed feedback about whether they felt there were consistently enough staff on duty. One relative told us there were, “Not always enough staff and sometimes delays in response”. We observed that there appeared to be enough staff working during our assessment. We saw staff responding promptly to call bells as needed. Call bell records were reviewed on a monthly basis to make sure people’s needs were being responded to quickly. We reviewed call bell records and saw people appeared to be responded to quickly.

Call bell records were reviewed and any delays over 5 minutes were reviewed ?

Call bell records are reviewed and any gaps are queried with staff- those gaps over 5 minutes.

The provider assessed and managed the risk of infection. People told us they felt the environment was clean and tidy. There was a clear infection control policy and procedure in place, which included relevant information and reference to up to date standards and legislation.

Staff had received infection control training and understood their responsibilities. Staff confirmed they were given the equipment they needed to maintain good infection control.

We observed staff wearing PPE where necessary and people had individual slings for their use where needed. The environment appeared clean and there were clear cleaning protocols in place to ensure the premises were hygienic.

The provider ensured medicines were given safely and met people’s needs. There were clear medicines care plans in place and these included details of what medicines people were required to take, when and why. Care staff recorded when people were administered their medicines on Medicine Administration Record Charts (MARs) and these were audited on a monthly basis. PRN protocols were usually in place and we saw these were administered safely. We identified one example of a missing PRN protocol and this was rectified quickly. Medicines were stored safely in accordance with requirements and although room temperatures were usually taken, we identified some gaps. We reported this to the manager who agreed to look into this to ensure temperatures were consistently monitored as required. They confirmed that this had been dealt with after our site visit.

We saw a robust process was in place for ordering repeat prescriptions and liaising with local pharmacies. Medicines no longer required were disposed of in line with current guidance, with records maintained. Regular audits of medication practices were carried out by the management team. Where issues were identified, action plans were put in place and followed up to completion.

Staff received annual training in medicines administration and had their competencies checked. There was an appropriate medicines administration policy and procedure in place.