The Dean Neurological Centre

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 means 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 medicines management.

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.

Staff listened to concerns about safety and investigated and reported safety events. Learning was identified and action taken to improve practice and processes.

There was evidence of learning taken from incidents, accidents and unexpected events. Actions resulting from lessons learnt were added to the service’s quality improvement plan and these had resulted in changes in some practice and process which supported improved safety.

We followed up actions taken following an unexpected event to see if these had resulted in safer practices and processes. On talking with a member of staff, they were fully aware of the subsequent lessons learnt and changes made to practice and process. This had resulted in nurses having more oversight of the planning and organisation of people’s external health appointments.

Staff knew how to report safety concerns, and they were confident action would be taken to address these. A member of staff said, “Managers will listen to me if I report something.” Safety concerns were recorded on the provider’s electronic records system as were incidents and accidents. This enabled senior managers to monitor these for patterns and trends and to ensure effective actions were taken to improve people’s safety.

The provider worked with people and healthcare partners to establish and maintain safe systems of care. Processes were in place to support continuity of care during admission, discharge and when people moved between different services.

Staff worked with commissioners to support admissions to the service including discharges from the Dean. One commissioner said, “I’ve worked with the admissions coordinator [of the Dean] for several years and have always found them to be friendly, responsive, and timely in handling any requests.”

People were admitted and discharged on different care and treatment pathways. A member of staff explained, irrespective of the pathway, a multi-disciplinary approach was adopted to support safe admissions, transitions and discharges.

The Dean had recently improved their processes to support effective communication between them and the services people travelled between.

A person told us, prior to their admission to the Dean, their previous care placement had not shared all necessary details about their health and care needs with staff. This had meant staff at the Dean had needed to follow this up to be able to support a safe transition and so they could ensure continuity of care once the person had arrived.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People told us they felt safe around staff. Staff completed training to help them recognise abuse, discrimination, poor practice and to report any concerns in accordance with the provider’s policy and procedures. The provider had zero tolerance of any form of abuse and discrimination, and people’s human rights were upheld. There were safeguarding leads within the service and at provider level and the service shared information of a safeguarding nature with us (CQC) and other agencies who have safeguarding responsibilities.

The provider took steps to avoid a closed culture by ensuring the service openly engaged with external agencies and professionals and that internal or external influences, which could support a closed or abusive culture, were monitored and action was taken to mitigate this.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In [care homes/hospitals], this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found risks of any form of unauthorised restrictive practice were monitored. Applications for Deprivation of Liberty Safeguards (DoLS) were made to the local authority. Mental capacity assessments and best interest decision records were reviewed to ensure correct measures were taken to protect people from unlawful care and treatment.

The provider did not consistently work effectively with people to understand and manage risks. Care was not always delivered in a way that was safe or supportive of people’s individual needs.

Risk assessments and care plans gave staff guidance on how to manage people’s risks. However, feedback from people and relatives was mixed. Some reported care was not consistently supportive in their managing risks. One person described their health condition, explaining that risks to them increased when they had to wait for care. They said, “I have been disappointed because the staff here really don’t seem to understand the life-threatening nature of the condition." Two relatives told us not staff had not managed their family member’s health risks effectively. Relatives also reported that measures were in place to reduce the risk of dehydration.

Records indicated that staff sometimes worked with specialist healthcare professionals to manage risks. For one person, this collaborative approach had contributed to wound healing. While records showed preventative care to protect skin integrity was provided, this person told us this care was inconsistent, although also said, “They (staff) must be doing something right.”

Risks associated with tracheostomies, suction, ventilators, and feeding tubes were monitored, with processes in place to respond to medical emergencies. Additional risk management support was included in one person’s care plan during periods of low mood.

Some individuals chose not to follow aspects of their care to balance risk with quality of life. Staff respected these decisions while ensuring people understood the risk. One staff member said, “I try to encourage [name] to have personal care, and help [them] understand the risk to [their] skin integrity.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The care home was purpose‑built and provided lift access to the first floor. Wide corridors and doorways and an open‑plan design for communal spaces, made it easier for people and their equipment to move around. This meant despite their disabilities people could socialise and move around independently if they were physically able to do so. All bedrooms were single occupancy with ensuite bathrooms and people had personalised these spaces.

Private and safe outside space wrapped around the back of the building. This could be accessed by people in wheelchairs or specialist seating systems, independently or with staff support. The service provided some specialist bathing and lifting aids although commissioners also considered people’s individual equipment needs when making funding decisions.

The provider’s estates and maintenance team ensured the building, its systems and utilities remained safe; supported by external contractors. Maintenance staff completed routine safety checks on large systems such as those linked to fire safety, electrical and gas fittings, heating, air conditioning, water supply and piped oxygen.

External contracts were in place to manage clinical waste and for maintaining equipment such as passenger lifts, hoists, beds and other health related equipment. Actions from the latest Legionella risk assessment had been completed.

Clear processes were in place for reporting maintenance and safety issues, supported by regular audits and health and safety governance meetings. Recent safety improvement work included the upgrading of window restrictors to include tamper proof fittings.

Staff received fire and evacuation training, exits and muster points were well marked. The local fire and rescue service had recently completed a planned visit to familiarise themselves with the building’s layout.

The provider sometimes did not have enough staff deployed to meet people’s needs. The provider did have processes in place to recruit staff safely, to train staff and to support them.

There were processes to determine staffing numbers, plan rosters ahead of time, review these along with skill mix and alter staff deployment where needed. The provider sometimes used agency staff to support staffing numbers. The registered manager confirmed staffing numbers were aligned to people’s needs and there were sufficient staff to meet these.

Despite this we received mixed feedback from people and their relatives as to whether they considered there to be enough staff to meet people’s needs. Most comments suggested, at times, there were not always enough staff.

Comments included, “No, not really, sometimes [relative] has waited half an hour on the call bell. If I’m there, I tend to go and ask someone”, “It can sometimes be a little hit and miss. Some shifts there are plenty of staff, but other shifts can struggle to be fully staffed” and “Sometimes when I’ve had to call for a member of staff to help me, I have had to wait a long time and I know it’s difficult for them because they have a lot of us to look after, but even just if someone could pop their head in the doorway to see if I’m all right, just to explain what’s going on and tell me they will be with me as soon as they can, it would really help. When the bell just rings and rings, you feel like you’re being ignored.” Another person said, “Staffing seems to be the biggest issue here, they are all rushed off their feet all the time.” Another person said staff come quickly and there is no waiting. Some people felt care was rushed at times and others did not.

A few relatives commented that new staff lacked knowledge and skills. The staff training record showed all staff completed relevant training and support was given to improve their knowledge and skills. Staff recruitment records showed staff were recruited safely.

The provider had processes in place to support good infection, prevention and control (IPC) although staff practices sometimes compromised the effectiveness of these.

All staff received relevant training; however, we observed moments of poor practice which showed staff were not always implementing their training. These included inconsistent handwashing and hand sanitising when moving between people and in particular during medicines administration. Other habits consisted of resting tablet computers on waste bins inside the entrance of people’s bedrooms and placing clipboards, holding care monitoring records, on the floor outside people’s bedrooms. Singular acts of poor practice were also observed such as 1 member of staff leaving 1 bedroom with a sheet for laundry, placing this in a laundry bag and entering another person’s bedroom without washing their hands.

We did also observe practices which supported good IPC. These included the donning and doffing of personal protective equipment (PPE) before providing personal care or before completion of clinical tasks. At mealtimes staff wore protective aprons when supporting people with food or drink and food was covered when transported.

Cleaning schedules were in place and cleaning records showed cleaning was completed. Staff were informed about any infections and were aware of the adjustments required to cleaning in such situations. Infection outbreak plans and procedures were in place.Processes were followed to reduce infection from equipment used to support people’s needs, for example, changes of urinary catheter bags and enteral feeding giving sets and syringes.

There were processes in place to monitor people for signs of infection so appropriate intervention could be taken. As part of the NHS Winter Preparedness program GPs were supporting people to access to Flu and COVID vaccines.

The provider had not ensured people’s medicines were managed safely to reduce risks to people associated with medicines administration.

Medicines were not always stored appropriately. Expired medicines were in stock and action had not been taken when the medicines fridge was not within an acceptable temperature range. This meant people could receive medicines that were not effective.

When medicines were administered, they were recorded on Medicines Administration Record (MAR) charts. The way these charts were written and checked for accuracy required improvement. Not all medicines were correctly written on the MAR as prescribed by the doctor. This put people at risk of not receiving their medicines as intended.

Where medicines were prescribed to be taken ‘when required’, protocols to guide staff on when to administer these were not always in place. Although staff were knowledgeable about people’s medicines, without protocols, people, especially those unable to communicate, were at risk of not receiving their medicines as needed.

The administration of thickeners was not recorded; this meant we could not be assured people’s swallowing risks were always appropriately managed. It was not always clear, which people required thickener and how these should be used.

Many people received their medicines via feeding tubes. MAR charts lacked detail on how these medicines should be administered. Additionally, required daily checks of feeding tubes were inconsistently recorded. This meant we could not be assured these medicines were administered safely.

Risk assessments for prescribed high-risk medicines had not always taken place. For example, 1 person was prescribed a medicine with an associated risk of bleeding, there was no guidance on how to manage this risk or what action staff should take if this occurred.

Medicines audits were completed; however, these had failed to identify the issues we found during this assessment. A medicines policy was in place but was not always followed.