Grenham Bay 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 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 people’s safe care and treatment including the ways people’s medicines were managed safely and safe recruitment of staff.

This service scored 53 (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. They did not always listen to concerns about safety and did not always investigate or report safety events. Lessons were not always learnt to continually identify and embed good practice. Staff reported incidents or accidents. These had been analysed to identify if there were any patterns or trends. However, when incidents had occurred, action had not always been taken to reduce the risk of them happening again. For example, a person had previously been found smoking in their room and was known not to want to give their lighter back. There had been no additional action taken to reduce the known risk. The person was found smoking in their room again and used the lighter to start a fire in the lounge. This had placed people and staff at risk. Following the incident, the provider put additional checks in place to reduce the risk of the incident happening again.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. There was a process in place to make sure information was sent with people when they transferred between services. However, the information was taken from people’s care plans, and these were not always detailed about people’s needs or how their conditions affected them.

People’s needs were assessed before they moved into the service to check staff were able to meet their needs. There was a comprehensive assessment in place, the information was used to form the basis of the person’s care plan.

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. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately. The registered manager had reported concerns to the local safeguarding authority appropriately. However, feedback from the local authority, following an investigation, identified the registered manager had not acted to reduce the risk of an incident happening again until it had been suggested by the local authority. Following the prompt the registered manager put additional risk assessments and management plan in place.

Staff had received safeguarding training. They described what signs to look for to identify if people were being abused and understood the process to report concerns. Staff were confident action would be taken when they reported concerns but knew how to raise concerns outside the organisation if needed.

The service had made Deprivation of Liberty (DoLS) applications to the local authority to deprive some people of their liberty appropriately. 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.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Potential risks to people’s health and welfare had not always been assessed and risk assessments in place were not always detailed or effective.

Some people were living with medical conditions including diabetes, epilepsy and lung conditions. These conditions and the symptoms had been recorded in people’s care plans but there was no information about the potential risks to people’s wellbeing. For example, when people were living with diabetes, their insulin was administered by the district nurse each day. However, there was no information about how people presented when they were unwell and the action staff would need to take if they showed signs of low or high blood sugar.

When people were living with allergies, there was information about what they were allergic to and the signs of anaphylactic shock. However, it was not clear if the person would suffer anaphylactic shock and what action staff should take if they did identify the person was unwell.When people’s needs changed such as requiring a catheter to drain urine from their bladder, staff had updated care plans that the person had a catheter but there was limited guidance for staff to provide support to the person and reduce the risk of infection.

Some people used a pendant around their neck to call for staff. However, the use of the pendant had not always been risk assessed. For example, when people spent all their time in bed or wore them while they were asleep. There had been no risk assessment about the risk of strangulation while wearing the pendant while people were asleep or if another option would be safer.

When people had been prescribed medication to thin their blood, there was a risk people would bruise easily or bleeding would not stop. There was no guidance for staff about what action to take if people fell especially if they hit their head as there would be an increased risk of bleeding.We could therefore not be assured that the provider was doing all that it could to mitigate risk to people to keep them as safe as possible.Relatives told us they felt their family member was safe living at the service. Comments included, “The staff know what they’re doing and she’s safe and well cared for there.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. There were effective systems in place to monitor and check the environment and equipment to make sure it was safe. The required checks had been completed on equipment such as hoists and boilers when required. The maintenance team completed regular checks on the fire safety equipment including the alarms and fire doors to make sure they were in working order. When shortfalls were found, action was taken to rectify them.Staff confirmed they had taken part in planned evacuation drills to make sure they understood how to support people safely during an emergency.

The provider did not always make sure there were enough qualified, skilled and experienced staff deployed appropriately. 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 always been recruited safely. The provider had not ensured the required pre-employment checks had been fully completed. Staff had not always been asked for a full employment history. The provider’s application form asked for the past 10 years employment history, when staff had not provided a CV, any gaps in employment had not been investigated. For example, a senior carer had been employed but the provider had not recorded their full employment history. Following our inspection the provider told us they had changed their application form.

The provider had not sought references from all applicants' previous social care employment. For example, references had been obtained from a staff member’s last 2 employers, which had covered less than a year. One employment was not in social care; however, the staff member had worked for over a decade at another care home. This employer would have been able to provide more relevant information about the staff members conduct. We discussed this with the management team, to draw their attention to the application form not requesting the relevant information.

There were enough staff to meet people’s needs, however, staff were not always deployed effectively. We observed the communal lounge in the morning. We found there were no staff present to support people with activities, and most people had no occupation apart from watching the television. We discussed this with the registered manager, who told us, the activities staff spent time with people who stayed in their rooms during the morning. We explored if this was the most effective use of their time in the morning, as other staff were supporting people with personal care. The registered manager agreed to look at the deployment of staff in the morning. Relatives told us there were enough staff and people did not usually have to wait long for the call bell to be answered. Comments included, “She has a buzzer round her neck, and she doesn’t have to wait too long for someone to come when she presses it.”

Staff had received training and supervision, which they told us were useful to discuss their training and development needs.

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. There were systems in place to maintain the cleanliness of the building. The service was clean and odour free. Staff had received training in infection control and wore personal protective equipment when required. There were appropriate systems in place for the disposal of waste and staff made sure these systems were followed. Relatives told us their family member’s rooms were clean and tidy. People had been supported to have vaccinations when offered.

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. The medicine trollies were not always stored safely. When the monthly medicine stock arrived, there was not enough room for 2 trolleys in the medicine room, and a trolley was stored in the hairdresser’s room. The trolley was not secured to a wall, as required, there was no room temperature recorded, and all staff had access to the room. We could not be assured that medicines were stored in line with good guidance.

Some people were prescribed medicines on a ‘when required’ basis such as pain relief or anxiety medicines. There were protocols in place, but these were not detailed and person centred. There was limited guidance for staff about when to give the medicines, how much, how often and what to do if the medicines were not effective.

There were effective systems and processes in place to order, administer and dispose of medicines. Staff maintained accurate records, they completed a tablet count at each medicine round to make sure people received their medicine as prescribed.Relatives told us people received their medicines as prescribed, “They look after her medications, their needs have changed since she went in there and they discuss what’s happening with me.”