The Spinnies

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

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 remained good. This meant people were safe and protected from avoidable harm.

This service scored 66 (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 new interim manager had prioritised the learning culture within the home as this had been identified in audits as an area for improvement. Staff confirmed that lessons learned were now shared as part of team meetings and supervisions. Where incidents had happened and staff had completed incident forms, the management team had consistently reviewed these to identify and mitigate any potential ongoing risk to people and shared the learning quickly with all staff to improve their knowledge and to ensure people’s ongoing safety.

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.

The provider had clear processes to assess and plan for people’s needs before admission. For example, they used an ‘enablement panel’ meeting for individuals who required additional support with managing specific health conditions. This process enabled managers to consult with senior managers who had specialist knowledge, ensuring that the service fully understood the person’s needs and could meet them safely before any transition took place. This helped prevent avoidable or inappropriate admissions and promoted smooth, well‑managed moves into the service. People also had important documents in place, such as hospital passports. These included personalised information about how individuals wished to be supported, their health needs and their preferred communication methods. This meant that if people needed to access other services, professionals had essential information immediately available. It helped people communicate their story without having to repeat information and reduced the risk of inconsistent or unsafe care during transitions.

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 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 staff had a good understanding of people’s personalised risks and safeguarding needs. People had a staff member who was assigned as their key worker. This meant staff were able to build trusting relationships with people. Staff we spoke with were extremely knowledgeable about safeguarding risks and what this meant individually to people living at the home. For example, staff were aware of people who were at a potentially higher risk of safeguarding concerns such as self-neglect or emotional abuse.

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.

Care plans contained clear guidance for staff on how to support people to take positive risks that aligned with their goals and promoted independence. Staff met with people monthly to ensure their care plans remained up to date and reflective of their needs. Relatives we spoke with confirmed they were kept informed of any changes and were included in annual reviews of their loved one’s care. One relative told us, “They [provider] always tell us about changes, whether that’s to do with the care or staffing, and we have an annual review as well.”

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 was responsive to immediate risks and repairs needed within the home to keep people safe. For example, on the day of our assessment we observed workman onsite replacing glazing that had become damaged the previous day. These works were planned to cause the least disruption to people including those with sensory needs that could possibly be triggered by loud noises or a busy environment. While the home needed modernisation and redecoration in some areas, the provider had a robust maintenance action plan in place to ensure this was addressed and people had been included in decisions about the home’s environment.

While the provider made sure there were enough qualified, skilled and experienced staff. They did not always make sure staffing levels enabled staff to provide safe care that met people’s individual needs.

The provider was actively recruiting for staff and a permanent manager for The Spinnies at the time of the assessment but had placed an interim manager into the home. The Spinnies was staffed to a safe level; however, people were not always able to access the community or activities of their choosing at a time appropriate to them. One staff member said, “Staffing has been an issue. We have had to cancel some activities. [Name] was due to go for a pub lunch last week and we had to cancel it as there wasn’t the staff to support them outside of the home.” A relative also commented, “The staffing is mostly okay, I know there has been a lot of sickness which has affected things like trips out, but I know [Name] is safe.”

The provider did not always assess or manage the risk of infection effectively. They did not consistently detect and control the risk of infection spreading or share concerns with the appropriate agencies in a timely way. During the assessment, we observed staff handling food without using the correct personal protective equipment (PPE), such as gloves. This significantly increased the risk of food contamination with bacteria, viruses, or physical objects, potentially placing people at risk of harm. We also observed some staff wearing artificial nails and nail polish, which further increases the risk of spreading infection.

This was fed back to the provider, who took immediate action by addressing the concerns with staff and refreshing their knowledge of infection prevention and control to ensure risks to people were mitigated.

Medicines were ordered, stored, administered and managed safely. However some medicine care plans did not always contain clear guidance for staff to follow. Temperature monitoring was in place and being undertaken. We reviewed medication administration records (MAR) and found people received their medicines including time sensitive medicines on time. When a person required their medicine at a specific time or with special instructions this was clearly recorded for staff to follow.

Staff had received medicines training including training for specific medical conditions and were assessed as competent to provide medicines support.

Medication protocols and care plans were detailed and individualised to each person. However, we found that not all medicines that were prescribed for ‘as and when needed (PRN) included sufficient information to guide staff on how to determine the correct dose when the prescribed dose was variable or required staff to make decisions outside of their training competency. Staff told us they would take immediate action to rectify.

Topical administration records were in place and completed appropriately. However, the risk assessments for the use of topical medicines for the people had not been completed. Staff told us they would take immediate action to rectify.

Staff reported medicines related incidents promptly, with documented actions and shared learning. Three medicines incidents reviewed during the inspection had been managed and escalated appropriately.

Medicines audits were completed regularly and action plans in place to resolve issues identified.