Delaheys Nursing 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.

This is the first assessment for this location under the new provider. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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.

Staff documented accidents and incidents and knew when to escalate concerns. There was a robust governance system to monitor and analyse incidents and learn from mistakes. Managers made changes to practice where required to improve care. Changes were communicated to staff and the reason for these. Staff gave examples of where safety incidents had been used as opportunities for learning. Learning from incidents had also been shared with other services run by the provider. This ensured that learning was proactive and risks to people were managed.

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.

Staff communicated well with a range of external professionals to ensure people moved between services safely. There was a pre-admission assessment process in place. This included recording people’s needs and preferences. Information about people’s needs was available to staff prior to people moving into the service. This maintained people’s safety. Referrals were made to healthcare professionals appropriately. Hospital passports were in place which detailed people’s needs. This is a document that details people’s medical needs, psychological needs and wishes and ensures that people receive the right support during a hospital admission.

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.

Staff completed safeguarding training and knew how to report concerns. There was a safeguarding policy in place and information was displayed for staff and people to refer to. People said they would be happy to raise concerns. A person said, “We have this way that works, if something is wrong, I will tell them.”

The registered manager made referrals to the local authority to raise concerns and made sure recommendations made were instigated and monitored.

The registered manager submitted Deprivation of Liberty Safeguards applications appropriately. Mental capacity assessments were carried out, and best interest meetings were documented. This helped ensure any restrictions were lawful.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Competent staff completed risk assessments and support plans, which were accessible on an electronic system. These were reviewed regularly and staff accessed them via handheld devices. People and relatives told us they were involved in care planning and reviews. A person said, “I was involved with my relatives care plan; they went through everything with me.”

Staff had good knowledge about how to manage people’s risk, however there was some inconsistency in a written risk assessment and the management of these risks. This was discussed on the day of inspection and immediate action was taken to address the risks. The registered manager completed a lessons learned report. This was shared with staff to address the findings.

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 provider ensured the building and facilities were suitable for the people who used them and in good condition. The premises were secure and included locked doors and tamper proof window restrictors. This helped to maintain people’s safety. Health and safety checks had been made within correct timescales, such as gas, electric and fire safety. Fire drills and checks of fire equipment had been undertaken at regular intervals. There was a maintenance person on site who checked the environment and fixed or replaced items when required. All equipment was serviced at regular intervals, and this was monitored. This ensured equipment was safe to use.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The provider recruited staff using a safe process and made checks such as references and disclosure and barring service (DBS). DBS checks provide information about convictions and cautions held on the police national computer. This information helps employers make safer recruitment decisions. However, we found gaps in employment history which had not been followed up. This had been identified by the registered manager on a recent audit, and they had started to take remedial action.

The registered manager used a dependency tool to make sure enough staff were available to meet people’s needs and preferences. Agency staff were used to cover holidays and sickness. The same agency staff were used to provide consistency.

Training compliance rates were high, and staff told us they completed a wide range of training and comprehensive induction. Staff received 1:1 supervision and appraisals which planned for their development. People said staff appeared to be well trained and knowledgeable.

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 home was clean and tidy. There was a cleaner and laundry staff who completed cleaning schedules and checklists. People said they were happy with the cleanliness of the home. A relative commented, “The home is clean, definitely.” And “[my relative] spilt his orange juice and they were here immediately and cleaned it up.”.

Staff understood guidance around minimising the risk of infection and followed these. Staff wore protective gloves and aprons during care delivery and discarded these in the appropriate waste bins. Gloves and aprons were available in all areas. Laundry trolleys were colour coded to enable this to be managed safely and in line with infection control guidelines.

At the time of inspection, the service was awaiting a re-inspection from environmental health in relation to the food hygiene rating. The service had made all recommended improvements that had been requested by the inspector. This helped ensure the safety of food hygiene practices.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Staff signed to show they had administered people’s medicines as prescribed. Individual guidance was available on medicines which had been prescribed to be given ‘when necessary’. Staff recorded the effectiveness of the medicine given. This helped to monitor outcomes for people. Medicines were stored securely and according to guidance. Staff recorded dates of opening medicines. People received time sensitive medicine on time, and this was well managed. Staff were observed administering medicines following best practice. People were not rushed and their medicine was explained to them. A person said, “The nurse brings it [medication] in morning and night – I trust them.” People received regular reviews of their medicines by health professionals, and this was clearly recorded.

The service had a nominated pharmacy. Audits to monitor medicine administration, recording and disposal were completed monthly. Stock counts were completed and medicine entering the home was checked and signed by two members of staff. This ensured medicines were stored and given safely. Regular checks on medicine administration was taking place, and any concerns were investigated and acted upon immediately.