Corbrook Park

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 people could be harmed.

The provider was in breach of two regulations in relation to safe care and treatment and staffing.

This service scored 56 (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. Lessons were not always learnt to continually identify and embed good practice. For example, concerns raised regarding communication, cleanliness, staffing and repositioning in meetings and surveys in July and August 2024 were identified as still ongoing during this assessment.

However, staff knew how to report safety events. Relatives told us they could raise concerns and felt listened to. Accidents and incidents were thoroughly investigated and feedback from staff confirmed the safety of people living at the service was a top priority.

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 manager was able to explain the pre-admission process and we saw that the provider implemented increased monitoring for all new admissions for the first 72-hours so that they could assess and get to know people in their new home environment. Staff told us they would also get to know people’s needs through handover meetings and via the provider’s electronic care planning systems. Comments included, “The nurses tell us about the [new] residents” and “We are made aware of [new residents’] needs via our handover and the care plan would be on the system.”

External professionals told us staff knew people well. One health professional told us, “Staff will have all the relevant information available.”

The provider worked well with people to understand what being safe meant to them and how to achieve that. They concentrated on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Feedback from staff and leaders confirmed they had completed safeguarding training and had a strong understanding of safeguarding procedures. The manager told us, “I speak to staff asking if they have any concerns.” Staff described the signs and symptoms of abuse and understood how to report any safeguarding concerns. Staff told us, “We report anything to the nurses” and “I would report anything I see.”

People said they felt safe and the manager understood their responsibilities in reporting safeguarding concerns to the relevant agencies, including the local authority.

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.

We observed unsafe use of equipment. For example, brakes were not applied to a wheeled weighing chair which could have caused harm. We fed this back to the manager, who added a sign to remind staff to apply the brakes. Staff told us information to manage risks was detailed in people’s care plans, however, one staff member told us, “It may not be up to date.”

We found care plans did not always have information to keep people safe. For example, where people required support with episodes of emotional distress, they lacked sufficient detail to guide staff in how to support people appropriately and safely.

We also observed that people asking for support were not always responded to in a timely manner.

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.

We observed broken drawers in 2 people’s bedrooms, floors in need of repair and sink areas in need of repair. We fed this back to the manager, who addressed the issues by ordering replacement drawers and scheduled in maintenance work.

People had an up-to-date PEEP (personal emergency and evacuation plan) and the service had a fire risk assessment in place to help ensure people could be removed from the building safely in an emergency.

Staff deployment was not effective to meet people’s needs when they needed it. For example, we observed one person calling out and not being attended to due to staff being busy completing other tasks such as serving meals and attending to people’s personal care needs. They did not always work together well to provide safe care that met people’s individual needs. For example, we heard one person being told by a staff member, “Listen to me, you want to go to the toilet, you want to go now, just wait okay.”

The provider did not make sure staff received regular supervisions and appraisals to support their development however, staff meetings did take place frequently. In 2024 18 out of 70 staff received no supervision at all.

Most people said there were not enough staff. Their comments included, “They could do with more staff”, “There is not enough staff here” and “When I need to ask for help I do sometimes have to press the call bell but I only ring the bell in an emergency. They do come after maybe 5, 10, 15 or sometime 20 minutes.” However, one person said, “I think they have enough staff.”

Regarding staffing levels, staff told us, “It’s terrible” and “Someone may miss out on a pad change and they are sat in urine and faeces for longer than I would like, they do get done, but they can wait 30 to 45 minutes.” Staff were concerned about people and told us people did not receive a wash until 2pm, 4pm, or sometimes 7pm. This was evidenced in the records we reviewed. Staff told us, “Staff numbers have been reduced, they did not increase staff during the outbreak, they keep decreasing the numbers.”

However, processes were in place to ensure staff were recruited safely and had completed all mandatory training.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

We observed areas of the service were visibly unclean. For example, there was black mould around a sink and worktops chipped. Some food was found to be out of date in fridges. Bed linen; bed bumpers; carpets and chairs were not clean. We observed one staff member was not bare below the elbow, ceilings were stained, and spillages wiped up without the appropriate cleaning materials.

We found no records in place for changing bed linen and carrying out deep cleans. We fed this back to the manager who introduced a deep clean form to use immediately. We were informed cleaning records for communal equipment were kept directly on the equipment, however, we observed several of these were missing.

At the time of our assessment the service was experiencing an outbreak of diarrhoea and vomiting and we observed staff used PPE appropriately and signage was in place. The provider had already identified some areas to be addressed on their home improvement plan.

The provider did not always make sure medicines were administered and managed safely.

Whilst staff had received training and their competency had been checked to administer people’s medicines, we identified concerns relating to the safe administration and management of medicines. For example, we found a tablet in a person’s bed, when we fed this back, we were informed the person who resided in that room had taken their medication as prescribed, therefore it was unclear whose medication it was and when it had been administered.. This posed a risk to the safety and wellbeing of others and a risk to the person who had not taken their prescribed medication. Records reviewed showed one person had received medicine prescribed for another person, however, as soon as the provider was made aware of this, medical advice was sought and followed. We also observed the staff member being interrupted while giving people their medicines, increasing the risk of errors being made.

The storage of medicines was safe. People’s care plans provided information about how to support a person to take their medicines.