Sholden Hall Residential 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 Requires Improvement. At this assessment the rating has changed to Inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in a continued breach of the legal regulation in relation to people’s safe care and treatment including the way risk was mitigated and managed in relation to people’s health, safety and welfare. This included concerns around the management of people’s medicines, fire safety and poor infection control.

The service was also in breach of regulations in relation to safeguarding and staff recruitment practices.

This service scored 28 (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. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice to improve safety.

Robust action was not always taken following some incidents. For example, people at risk of absconding had further risk mitigation strategies put in place following incidents where they had absconded. These strategies had not always been adhered to and further similar incidents had occurred. For example, a person required enhanced supervision and support from staff at particular times of day and when looking for exits from the service. However, this had not been consistently and effectively implemented to prevent further incidents of absconding. People were placed at increased risk of avoidable harm.

Accidents and incidents were recorded by staff however these were not always detailed, complete or timely accounts of incidents that had happened. For example, an incident occurred involving 2 people living at the service, but the incident report lacked complete and accurate details about what happened.

Another person who was at risk of their health deteriorating had a retrospective entry put in their notes to state staff had been providing the necessary care. There was a risk that the accuracy of the information could be compromised and could result in errors in the person’s care.

The provider did not always have a clear overview of incidents and accidents in order to be able to identify patterns or trends or improve service delivery.

The provider did not always work with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored.

The provider carried out initial assessments of people’s needs prior to them moving into the service. People and relatives told us they were involved in these assessments. Referrals were made to other health care professionals to seek support and advice about how to meet people’s needs. Professionals told us the service contacted them for guidance and made appropriate referrals based on people’s health needs.

However, guidance given by healthcare professionals was not always followed. The provider had not always recognised when safety had not been well managed or monitored. They had not always reported or robustly followed up concerns with other professionals such as the local authority or the Care Quality Commission

Despite this, people and those important to them told us they felt safe at the service. A person told us, “I feel safe living here, having people around me all the time."

The provider did not concentrate on improving people’s lives or protecting their right to live in safety, free from potential abuse, discrimination, avoidable harm or neglect. The provider did not always share concerns quickly and appropriately. The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that.

Staff had completed safeguarding training and told us they knew the signs or symptoms which might indicate someone was experiencing abuse and felt confident to escalate any potential concerns within the service as well as to outside agencies.

However, the provider’s processes to support safeguarding had not been effective. Potential safeguarding concerns had not always been identified by staff, the registered manager or provider. Some people had been subject to instances of unplanned restraint. Staff had not completed relevant decision-making records in partnership with appropriate others to ensure that instances of restraint were lawful and in line with the Mental Capacity Act 2005 (MCA). Staff had not received accredited training to reduce the risk of potential harm to people from unauthorised restraint techniques. Following the inspection the provider ensured some staff completed accredited training for physical restraint. The registered manager and provider had not focused on people’s experience in these situations as a potential safeguarding concern. We raised these incidents with the local safeguarding team following our inspection.

The service had made Deprivation of Liberty (DoLS) applications to the local authority to deprive some people of their liberty. This is a necessary legal procedure to follow when a person who lacks capacity to consent to their care and treatment requires restrictions in order to keep them safe from harm. However, the use of restraint for some people living at the service had not been considered as part of DoLS.

The provider continued to not always work well with people to understand and manage risks. At the last inspection we found concerns with diabetes management. At this inspection we continued to have concerns around diabetes management. Staff did not always provide care to meet people’s needs that was safe and supportive. Records in relation to managing a person’s diabetes did not contain consistent and detailed person-centred guidance to support staff in how to monitor the person’s blood glucose levels, what their normal range was and what to do when their blood glucose levels were high. When the person’s blood glucose levels were deemed high there was no recorded immediate action taken to help reduce the person’s blood glucose levels. This placed the person at risk of their condition worsening and their health deteriorating. There were also no record of follow up checks being undertaken to ensure the person’s blood sugar levels did not remain high or continued to increase. The person was placed at an increased risk of harm. Following the inspection site visits the person had had another high blood glucose reading and further testing. The person’s risk assessment and care plan were updated and sent following the inspection and there was some improvement in the level of detail recorded.

Where people were at risk from dehydration there was not always clear fluid targets to support staff to monitor people’s fluid intake. Some people at risk had low fluid intakes recorded. This placed people at potential risk of their health deteriorating.

Some people required enhanced monitoring by staff to ensure their safety and emotional well-being. There had been repeated incidents of people absconding from the service. Staff had not always followed their risk mitigation to ensure people’s safety and to meet their individual needs. This placed people at risk of avoidable harm.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

People had not been protected against environmental risks such as the risk of fire. There had not been a recent fire drill which simulated reduced staffing at night. Although, staff had completed fire safety training, some staff had not taken part in fire drills or did not know how to carry out an evacuation safely. This meant the provider had not assured themselves staff could support people safely, and in a timely manner, in the event an emergency evacuation was required at night. We raised this concern with the local fire service who carried out a visit and confirmed work needed to be done to ensure the service was compliant. The provider conducted a fire drill with the number of staff that would be on shift at night following the inspection.

The home environment had not been fully maintained and risks mitigated, such as a hot water tank cupboard not having a secure lock to prevent the risk of people touching hot pipes. There was damaged equipment in a bathroom that was not fit for use by people which posed a potential risk to people’s safety. However, the provider told us people’s preference was to use the other bathrooms to wash, although people still used the bathroom for the toilet and hand washing facility. Furnishings within the home had the potential to pose risk to people’s safety such as broken loose tiles in a fireplace and a broken radiator cover in a bathroom had not been made safe. We fed this back to the provider who acted after our first site visit to address concerns.

Other environmental checks had been completed such as gas and electrical safety, and mobility equipment was serviced in line with best practice guidelines.

The provider did not always make sure there were enough qualified, skilled and experienced staff effectively deployed to meet people’s individual needs. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Staff had not been recruited safely. Staff recruitment files did not always contain a full employment history, which the provider is required to obtain, with any gaps in employment explained. The provider had not assured themselves that staff were suitable and safe to work with people. However, the provider had sought references for new staff and completed Disclosure and Barring Service checks as required. Following the inspection the provider shared documents evidencing staff full employment history had been obtained.

The provider had calculated their staffing levels using a dependency tool and were staffing the service above the required levels. We observed most people’s needs were met in a timely manner and there were now enough staff to meet people’s needs. However, we observed at times staff did not always maintain effective deployment to support robust risk mitigation for example, where people required additional supervision for their well-being or safety.

We received mixed feedback from people about the staffing levels in the home. A person told us, “Probably need more staff at night, when some of the [people are upset], but it doesn’t happen often… Sometimes they’re delayed but it’s because they’re with other patients.” Staff told us they felt there were enough staff day and night to keep people safe and meet their needs.

Staff received mandatory training at varying intervals from yearly to three yearly. Mandatory training covered essential training such as Safeguarding, Mental Capacity Act, Infection Prevention and Control and Fire Safety as well as training to support staff to meet people’s individual needs such as Dementia and Diabetes awareness. Although, staff training was in date, given the issues we found in relation to these areas of practice, reported on throughout the safe domain, we could not be assured staff training was effective at ensuring staff practice was always safe and met people’s needs. The provider ensured staff completed restraint awareness training and refreshed Deprivation of Liberty Safeguard training following the concerns raised during our inspection.

The provider did not have effective infection control processes in place to both assess and manage the risk of infection. Systems and processes to detect and control the risk of infection spreading were not robust. Staff told us cleaning was completed during the day and night and that this was recorded. A person told us, “My room is good. I have my own things in there and they keep it clean, my bed gets changed and they whip away my clothes for wash so I wear clean clothes every day.”

However, we saw the home was not clean in all areas. We observed frequent touch areas such as doors and banisters were dirty and sticky to the touch and windowsills were dusty with dead flies on them. Bathrooms needed deep cleaning to remove limescale. We saw cleaning rotas had not been signed to confirm the bathrooms were cleaned on a daily basis. People living at the home were placed at an increased risk of infection. We addressed this with the provider who cleaned and painted the woodwork in the home following our inspection.

We observed staff used personal protective equipment when required such as, supporting people with their personal care needs.

Although, people told us staff managed their medicines well. The provider did not always make sure medicines and treatments were safe and met people’s needs.

Staff had completed training to administer medicines and told us they had their competency assessed. However, we found multiple issues with medicine management. For example, medicines had not always been stored safely. We found 1 person had 2 loose PRN (as required) tablets inside their medicine box which should not have been there. This placed them at risk of not receiving their correct medicines as prescribed.

During our first day at the service, we observed the medicines room was unlocked, and the door was open; we saw a person was sat next to the medicines room and no staff were in the vicinity. There was a risk that medicines could be accessed by unauthorised persons and placed people at risk of potential harm. Following the inspection the provider sent us a record to demonstrate how they monitored when the medicines cupboard was locked and unlocked. However, this did not reflect whether staff always supervised the unlocked room.

Stocks of medicines had not always been managed safely; we found stock totalling errors as well as liquid medicines without open dates. It is important for open dates to be recorded on medicines to ensure they remain in-date and effective.

We also found staff had not followed manufacturers guidelines for administering 1 person’s pain relief medication patch which placed the person at an increased risk of experiencing skin irritation.

We raised our concerns about medicines management with the provider. They sent us records following the inspection to demonstrate improvements in their medicine management processes.