Driftwood 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. This is the first assessment for this newly registered service. This key question has been rated 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 safe care and treatment including poor medicines management.

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. 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.

Although the provider had systems in place to investigate, review and learn from accidents and incidents, they were not always robust. For example, staff meeting minutes demonstrated the provider had recently outlined to staff the potential dangers of items which people living with dementia might try to eat thinking they were food. However, despite this being very clearly documented we found multiple examples of items, such as toiletries and surgical gloves, being accessible to people which could have placed them at risk. The provider took prompt action to address this and by our second onsite visit this had improved.

We found good systems in place to review fire drills to enable staff to review actions taken to see if anything could be improved. Accidents and incidents were logged and reviewed by the manager, but some records had not been fully signed off.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Healthcare professionals were positive about how the service engaged with them when people moved from other settings, such as a hospital. Relatives told us communication had been effective when moving their family member to the service which had helped people settle in.

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.

Staff received relevant training and were able to tell us their responsibilities related to keeping people safe from abuse. The provider had reported concerns to the local authority and to CQC as required, in most cases. However, we also identified some instances where this had not happened. This demonstrated the process was not fully robust and the provider acknowledged this and gave us assurances that the newly appointed quality assurance manager would have better oversight of this in future.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes 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 that where people had been deprived of their liberty under the Deprivation of Liberty Safeguards in order to be safe, some records were due for review and the provider was aware of this and had begun reviewing. Appropriate authorisations had been submitted to the local authority for urgent authorisations, but action was not always clearly documented when standard authorisations had been delayed and not yet granted. Staff received training in DoLS but one staff member was not clear if a person had a DoLS in place or not when we discussed this with them. Staff needed to be clear about people’s status with regard to DoLS to ensure their rights were upheld.

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

Although there were systems in place to manage a variety of risks, records did not always demonstrate care was being provided in line with people’s needs. For example, pressure care risks were assessed but records did not always demonstrate people were being repositioned in line with their care plan. One person’s repositioning record had gaps of over 8 hours on multiple occasions. There were no issues with pressure care at the service and we did not judge anyone had come to harm and the provider felt this was a recording rather than a care issue. However, there was a risk systems were not fully protecting people. This was also the case when reviewing the risk of dehydration. Records made it difficult to be easily assured people were receiving the fluids they needed. However, we noted jugs of juice were regularly refreshed and had no concerns of anybody coming to harm.

Falls were well managed and there were plans to introduce new falls monitoring systems which the provider had commissioned from a technology provider, to further reduce risk.

Risks relating to fire, which had previously been a concern at the service, were very well managed. Staff were well trained and the provider carried out regular fire drills followed by in-depth reviews of how these had gone.

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.

The service was mostly safe and suitable for the client group. However, we noted some environmental risks which needed further assessment and mitigation. The provider was partway through a renovation and redecoration programme, and some risks had not been assessed whilst this was underway. We noted some unlagged pipes in the hairdressing salon, tools left out and paint and toiletries accessible to people who might access them and harm themselves. We were concerned that items such as surgical gloves were being stored in corridors and fully accessible and we saw one person living with dementia take a box of gloves to their room. We brought this to the immediate attention of staff who removed them and the provider has removed gloves and other items and made suitable storage for these since our onsite visit.

We also noted a potential fall hazard in an unguarded area of the main stairs. The provider has told us they have already taken steps to address and mitigate this potential risk.

Safety systems such as the fire system, fire-fighting equipment, moving and handling equipment, gas and electrical systems were routinely tested and well maintained.

Although the provider made sure there were enough qualified, skilled and experienced staff to meet people’s needs, recruitment processes required some review. We identified one person had only one reference on file and another had two but not the most recent one which was from a care position. This meant the provider risked not having a complete picture of the person before employing them which could pose a potential risk. All other recruitment records were present and of good quality.

Staff worked together well, and people and relatives told us there were always enough staff to meet people’s needs. One relative said, ‘[Staff] know my relative well. Yes, very much so. [There are] always, more or less, the same staff on which [my family member] trusts too.’ Care staff told us there had been a shortage of cleaning staff recently which had impacted on the cleanliness of the service and resulted in an additional workload for care staff., This situation had recently improved, and additional cleaning staff employed.

Staff received a comprehensive induction and ongoing training to check knowledge and skills. Staff told us they felt confident in their role and felt well supported with training and development opportunities.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We noted an external company had identified a possible presence of legionella bacteria in the water system during the annual test in November 2024. The system was re-tested the following March and found to have no risk. Between November and March the provider carried out weekly flushing of vulnerable areas of the water system and tested weekly to ensure water was being stored at the correct temperatures. However, it was not clear why there was a delay in fully addressing this potential risk to people’s health before that time and the provider acknowledged this.

Staff received 6 monthly infection prevention and control online training. However, although most areas of the service were very clean and free from odour, we found the kitchen and medication storage areas required a deep clean and improved systems to oversee cleaning in these areas. The cooker was not clean and there were no recent records relating to its cleaning. The medication cupboard upstairs and medication room downstairs were disorganised and needed cleaning. We discussed this with the provider at the end of our first day onsite. They acknowledged our findings and by the time we visited for a second day things were much improved in all areas, with a commitment to ongoing oversight of these areas in future. The laundry was well organised, although in need of some refurbishment, and staff were clear about their role in preventing the risk and spread of infection.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Medicines management was poor. We observed disorganised and unhygienic storage of medicines and a lack of effective systems to administer medicines safely and audit them. It was impossible to establish if people had received the medicines they needed as one tablet had been dropped on the floor of the medicines cupboard, others were found unlabelled in medicine pots and reasons for medicines not being given were not always clearly recorded. The provider acknowledged there was a need for total reorganisation of the storage, recording, auditing and disposal of medicines to ensure they were safe. By the time we carried out our second onsite visit a week after our first, the situation was much improved.

Staff received relevant medicines training and their competency to administer medicines was regularly checked.