Coton House

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.

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 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 provider had a system in place to review accidents and incidents. The registered manager told us they carry out a root cause analysis to analyse incidents and identify themes and trends. For example, the provider had carried out an analysis of falls. This identified a pattern of falls happening in the early hours of the morning in the lounge. In response to this the registered manager employed an additional member of staff. Staff told us information about learning from incidents was shared with them during handover.

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. The systems in place to support people were not consistently working to ensure people were supported safely. Where people’s health needs had changed the systems in place did not ensure escalation to a relevant health professional. This meant people did not always have their care needs met safely.

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. The provider shared concerns quickly and appropriately. People told us they felt safe at Coton House. One person told us, “I have been here for two years, and I like it very much. They are not strict at all – it’s like home from home.” Another person told us, “They are regular staff, and I feel at ease with them”. A relative told us, “They are kind and things are working well. She’s safe here.” Adding, “One thing I am pleased about is that she is safe and well looked after.” Staff understood how to recognise signs of abuse and knew how to report any concerns. Incidents were referred to the appropriate safeguarding body for investigation. The registered manager told us they carry out root cause analysis when a safeguarding occurs to consider any learning and look for areas of improvement. Where people were being deprived of their liberty, applications had been sent to the authorising body and these were referenced in people’s care plans. The applications however, had not fully considered all restrictions. For example, bed sensors. The registered manager told us she would discuss this with the authorising body after the inspection. Where the use of CCTV was being used, there was no consent forms residents nor any Mental Capacity Assessments.

The provider had systems in place to identify risks to people and put plans in place to manage these. However, risk assessments and management plans were not consistently followed. For example, one person’s diabetes risk assessment and care plan required staff to test the person’s blood glucose levels twice a day and record this to manage risks relating to low or high blood sugar. The staff had not followed this plan for a month and the person’s blood sugar was only being monitored once a day. The person’s blood sugar was high for over a month and there had been no escalation of these concerns by staff in line with the person’s risk assessment and care plan. This meant the person was placed at risk of their health deteriorating. The registered manager told us since the inspection they have introduced monitoring to ensure blood sugar testing is completed in line with individual risk assessments and care plans. Staff had good knowledge of people’s risks, including the risks relating to, falls and skin integrity and were observed following the risk assessments and care plans to keep people safe. People told us they felt safe at Coton House, and relatives felt people were safe too. People told us it was “homely”.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, and facilities supported the delivery of safe care. We saw radiator covers had gaps at the top, this meant people were at risk of harm from burns and scalds. The registered manager arranged a repair immediately and confirmed this following the inspection. The provider told us work was underway to refurbish the home. Relatives told us “Looking around you can see that a lot of work has started but not yet finished, they need to get the builders and decorators in.”

The provider made sure there were enough qualified, skilled and experienced staff. The staff worked together well to provide safe care that met people’s individual needs. The registered manager told us they used a tool which worked out how many staff they needed to support people based on their individual needs. We saw this had been effective in ensuring there were enough staff to support people. Our observations showed staff were prompt and responsive in communal areas. Staff told us they felt there were enough staff. Staff were recruited safely. The provider had a policy in place which ensured safe recruitment practices including references to check on staff suitability for working with vulnerable people. We saw staff had regular supervision. People told us they felt there were enough staff to support them and they were all supportive and understood people’s needs. A person told us, “The staff are very good, and nothing is too much trouble for them. I think there are enough of them, and they are always there.” A relatives told us, “Yes, I think she is safe here. Staff are caring and on the ball. They are all very friendly and helpful.” We saw staff were prompt and responsive to people needs in the communal area where they needed assistance with mobilising.

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 provider had a policy in place for Infection prevention Control (IPC). We saw the providers training matrix which showed staff had received infection control training. Staff told us they had access to Personal Protective Equipment (PPE), and we saw staff used this safely. The registered manager told us they carry out spot checks to ensure staff are using the correct PPE.

The provider’s medicines administration systems did not always ensure medicines were managed safely. The provider’s systems did not ensure accurate recording of medicines stock. We checked medicines records and stock and found these did not match. The systems in place to monitor this had not identified these discrepancies. Where people had ‘as required’ medicines, guidance was not always in place to ensure this was administered in line with how it was prescribed. This meant we could not be sure people were receiving their medicines as prescribed. Staff told us they were aware of the missing ‘as required’ guidance; however, these were not implemented once it was identified. Since the inspection, the registered manager has told us that all protocols are now in place. We saw missing signatures on medicines administration record (MAR) sheets with no explanation and no escalation. Staff are aware of the procedures for reporting concerns with medicines but had not taken the action required to report the concerns. However, people told us, they received their medicines as prescribed. A person told us, “They are very good with medicines, and they are now applying eardrops because I am losing my hearing.” A relative told us, “My relative is diabetic, and they sort all their medicines out. They are always clean and tidy and well looked after.” Partners told us they had observed the medicines administration appeared to take long period of time in the morning. We observed during the inspection the medicines round took over 2 hours to complete. There was a system in place to ensure people had the right gap between the medicines when this had been administered late. We spoke to the registered manager about this, and they told us the staff administering medicines was no longer doing this until further investigation.