Bankfield House Care 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 remained 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 and good governance.

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 promoted a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety, and safety incidents were investigated and reported. Lessons were learned to support ongoing improvement and embed good practice.

The registered manager had systems in place to ensure lessons were learned and shared. Following falls, analysis was undertaken to understand how incidents had occurred. We spoke with the registered manager about the need for post-incident reviews to clearly demonstrate timely actions, such as referrals to other agencies or consideration of alternative equipment where appropriate.

The registered manager displayed information leaflets in staff areas to support and improve staff knowledge and practice. The registered manager was responsive to our feedback and took immediate action to address the concerns we raised.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, where safety was effectively managed and monitored. They supported continuity of care, including when people moved between different services.

The registered manager had systems in place to ensure appropriate assessments were completed before people moved into the home. People were generally satisfied with the arrangements for living at the service. One relative told us, “We didn’t think [family member] would last long, and they were uncooperative. Their deterioration was shocking. However, since being here, they have really improved. Staff put care plans in place and adapted them as things changed. They have been absolutely brilliant.”

The provider worked with people and healthcare partners to understand what being safe meant to them and how best to achieve this. Staff focused on improving people’s quality of life while protecting their right to live safely, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared safeguarding concerns promptly and appropriately.

People generally felt safe living at the home, and relatives’ feedback about the staff team was positive overall. One relative told us, “[Family member] is safe there and gets on with the staff.”

The registered manager had systems in place to ensure safeguarding concerns were raised and investigated appropriately.

Where people lacked capacity, mental capacity assessments had been completed, and best interest decisions were made with the involvement of relevant people. Where people were subject to restrictions, referrals had been made to the Deprivation of Liberty Safeguards. The registered manager had systems in place to monitor when authorisations required renewal and to ensure any conditions attached to authorisations were tracked.

The provider did not always work effectively with people to understand and manage risks. Staff did not consistently provide care that was safe, supportive, and enabled people to do the things that mattered to them.

People’s needs and risks were not always clearly recorded in risk assessments or care plans. We found that information within care records was sometimes inconsistent or inaccurate, for example in relation to the equipment people required. People were not always supported safely with moving and handling. For instance, slings were not always positioned correctly for people who required hoisting. Where people were transferred in wheelchairs, it was not always clear the use of lap belts had been appropriately assessed by a suitable qualified professional. There was inconsistent practice across the staff team, and following inspection the provider told us the information in some people’s care plans about lap belts was inaccurate. We were not assured that people’s safety had been prioritised.

A range of risk assessments had been completed and were reviewed on a regular basis. Equipment was in place where required, for example for people at risk of falls. The registered manager told us they were in the process of purchasing new sensor alarms for some people. The home had also recently started working with an evidence-based falls prevention programme to support people’s mobility. Staff demonstrated an understanding of people’s basic needs.

The provider did not always identify and manage potential risks within the care environment. They did not consistently ensure that equipment, facilities, and the environment supported the delivery of safe care.

The provider had an ongoing programme of redecoration, and some communal areas were still being refurbished at the time of our visit. One relative commented, “I have found the staff are genuinely caring, and I am not bothered if some paint is chipped as long as mum is being looked after properly.”

There were checks of equipment in place, and the registered manager carried out regular walkarounds of the building. However, we identified two wardrobes that were not securely fixed to the wall, and we asked the registered manager to address this. We also found several radiator covers that were either missing or not securely attached. We identified gaps in records, which meant there was not sufficient assurance that fire risk assessments were reviewed regularly or that appropriate action had been taken in response to temperature checks of water. These concerns were fed back to the provider for action who provide assurances that these matters either had or would be addressed.

We noted improvements in the management of the call bell system. Most people had access to a call bell, or a sensor mat was in place where appropriate, and airflow mattresses appeared to be set correctly.

The provider did not always ensure there were enough qualified, skilled, and experienced staff. They did not consistently ensure staff received effective support, supervision, and development, or that staff worked together effectively to provide safe care that met people’s individual needs.

People told us there were not always enough staff available to provide timely support. One person said, “I've had the odd fall out here and there with them, but nothing serious. On the whole they are helpful. It’s just sometimes at busy times there aren’t any staff around and I have wet myself three times as a result. If I ask and they say they’ll be five minutes, fifteen minutes later I can’t help it — my bladder isn’t what it was.”

We observed that staff were often very busy and focused on completing tasks throughout the day. Some staff told us they would like more time to spend with people to provide higher-quality care and support. There were periods when staff were not present in communal areas, and on one occasion inspectors needed to locate staff to urgently assist a person.

Although staff had completed a range of training, our observations did not consistently demonstrate that this training was effective in practice, particularly in relation to moving and handling. The registered manager told us they had introduced a monthly training focus to develop staff skills. They had recently provided additional training on mental capacity and, at the time of our inspection, were focusing on skin integrity, including arranging face-to-face training for staff.

Further improvements were needed to recruitment processes to ensure robust checks of staff’s work history and character were completed promptly, prior to employment. The registered manager responded positively to our feedback and took action to address gaps identified in the records we reviewed.

The provider did not always assess or manage the risk of infection effectively.

Most areas of the home were clean. However, we found areas of damaged plaster, woodwork, and furnishings, which meant that good infection prevention and control practices could not always be maintained. The local authority’s infection prevention and control assessment had improved since our last visit. One relative told us, “The place is immaculately clean, and any accidents soon get sorted out.”

We identified some gaps in staff training, including in infection prevention and control and the safe management of cleaning products. We asked the registered manager to review training to ensure all staff had completed training relevant to their role.

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.

Records for adding thickening powder to drinks for people who had difficulty swallowing were not always completed accurately. Therefore, we could not be assured that people were always safe from the risk of choking.

Medicines rounds were not always personalised to ensure that people were given medicines at appropriate times. For example, we saw that a medicine round occurred when some people were asleep. Therefore, they did not always receive their medicines.

When medicines were given to people, we were not always assured that they were given at the time stated on the medicine’s records and in accordance with manufacturer’s instructions. For example, if a medicine needed to be given before food.

Whilst staff demonstrated good knowledge of people’s medicines needs, care plans did not always have up to date, personalised information about how to support people with their medicines.

Information to support staff to safely give ‘when required’ medicines was in place. However, this was not always correct or up to date. This meant there was a risk people might not have got their medicines when they needed them. Once the ‘when required’ medicines had been given, the outcome was not always assessed and recorded. Therefore, staff did not always know if the medicines had been effective.

Medicines audits were carried out regularly. However, they were not effective in identifying medicines-related issues occurring in the service. Medicines errors were reported and appropriate action was taken. However, medicines errors were not always identified as discrepancies were found during this inspection.