Good Shepherd 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 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 people’s safe care and treatment.

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.

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.

Risks to people were not always used to learn and improve. For example, where people required increased checks following an incident where they had sustained an injury. We found the records of these, along with actions taken at the time of the incident were spread across multiple documents. This made it challenging for staff to understand what risk mitigation was in place and for the service to effectively monitor for themes.

However, we found the management team were open and transparent and wanted to drive improvement at the service.

The management team understood their responsibility to report incidents to the relevant authorities. However, we found the recording process used for this was not being followed by all staff. The registered manager shared evidence of an improved process they had developed and plans to ensure this was embedded moving ahead. We will review this at our next assessment of the service.

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 service worked well with external professionals to ensure people received timely support for their identified health and social care needs. For example, where equipment was required, or a review needed to be completed of a person’s clinical diagnosis. We received feedback from the covering GP practice, who advised that the service engaged with them well, and ensured they made prompt referrals where a change in a person’s presentation was observed.

Relatives felt their family members were safe. One relative told us, “Oh yes, my family member is so much safer here. They’re so open and just tell us as it is. We’ve no complaints at all, it’s spot on.”

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.

The management team understood their responsibility to ensure incidents were reported promptly to the local authority and the CQC. However, these referrals were not being made consistently and promptly, as required. The registered manager shared a revision of their safeguarding referral process for the staff team to use moving ahead. However, this process was not fully embedded at the time of our assessment visit. We received no concerns from relatives regarding safety. One relative told us, “My family member is safe enough and well treated. When they could talk, they were obviously happy here.”

There was a lack of robust processes in place for the management team and staff to review incidents. This meant the registered manager could not analyse themes or enable information to be shared at staff meetings and individual supervision sessions.

There was a provider policy for the duty of candour. This policy guided the service to tell the person, or where appropriate their advocate, when something has gone wrong. We reviewed complaints that had been made and saw this policy had been followed by the management team.

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.

Risk assessments had not all been reviewed and updated in a timely manner to ensure risk was mitigated. Care records lacked evidence of review and completeness for some people.

Some information within people’s care records was contradictory and had not been promptly updated after an incident, or a change in need was identified. For example, where people lived with skin management needs; care records had not been reviewed or risks promptly updated within people’s care plans.

People we spoke with or observed appeared to be satisfied with their equipment provision and safety devices. We observed staff hoisting a number of people during the day. These manual handling procedures were carried out in a calm, efficient manner with nice interactions between staff and people. Relatives told us that staff understood their family members’ needs well and offered support to keep them safe. One relative told us, “My family member has everything they need, they get hoisted carefully and staff know their needs well.”

People and their relatives told us they were able to communicate their or their family members’ needs, to ensure they received the right type of support.

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 found personal emergency evacuation plans were not located in the service but were stored in the adjoining service, making them inaccessible in the event of an emergency. Incorrect details were recorded for some people in the service, regarding their evacuation needs. Signage on people’s bedroom doors was handwritten, and not clear. Although staff had clear processes in place for how to respond to an emergency and the evacuation processes to follow. The deputy manager responded to our concerns raised on site, and ensured these documents were reviewed and updated to fully consider the unique needs of people.

The exterior of the service was not a well maintained or pleasant space for people to spend time outside with their relatives.

Staff knew how to monitor the safety of the environment, and where to report any maintenance concerns to. The management team described a clear process for monitoring environmental safety concerns. The environment was kept safe, by regular checks and maintenance. Systems were in place to ensure the water quality was maintained to reduce the risk of water-borne bacteria (like legionella). The gas heating system was regularly serviced to prevent harm to people.

The provider made sure they employed qualified, skilled and experienced staff, who received effective support, supervision and development. However, we found the staffing levels were not always planned effectively to provide safe care that met people’s individual needs.

The staffing rota and deployment records for the service required updating, as they showed that some people living at the service required the assistance of 2-3 staff members for all personal care needs. Nursing staff were working across 2 services, providing clinical support for the nursing beds in an adjoining location.

During our review of care plans we saw that it was recorded that some people often required 2-3 care staff for personal care and repositioning. For example, 1 person required 3-4 staff to assist with hoisting needs and the changing of their tracheostomy tube every 4 hours. This would not leave sufficient staff on the unit to care for the other people. The deputy manager advised that the care plans required updating, as people mainly required only 1-2 staff. This confusion around safe staffing ratios left people at risk of having unmet needs.

Relatives we spoke with felt that staffing was adequate and their family members were well treated. A concern was raised however, about incidents of insufficient staff being available to accompany a person to the hospital. A relative told us, “Most of the time staffing seems ok. There’s always staff upstairs if needed, and they are more attentive to my family member here than in hospital. But twice they have had to go to hospital since being here, and both times they didn’t have enough staff for one to go with them in the ambulance.” We raised this with the registered manager to review their policy and process for providing a chaperone to hospital visits.

Staff had received suitable training to do their role. The management team ensured there were always suitably skilled staff working. Once staff were trained, there were clear ongoing processes to assess their competency. If needed, further support and training was then given to improve staff skills. If staff were not providing the expected level of care, there were clear processes to monitor and improve their performance.

Safe recruitment processes were followed. For example, previous employers were contacted to give references on the staff member. Staff had regular Disclosure and Barring Service (DBS) checks. These check the police database for convictions or warnings that may impact the staff member's safety to work with people.

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 service was clean and well maintained. Relatives we spoke with were positive about the cleanliness of the environment. One told us, “It’s kept very clean everywhere. My family member is supported to shower a few times a week and is kept clean, with fresh bedding too.”

There were clear processes and policies in place, to ensure people were protected from the spread of an outbreak or infection. If an infection outbreak occurred (for example diarrhoea and vomiting), there were clear processes in place to reduce the risk of this spreading to other people at the service.

Staff had received training in infection control, how to put on protective equipment and how to keep people safe in the event of an infection outbreak.

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.

People’s medicines were stored and administered in a safe way, by competent, trained staff. No concerns were raised by relatives on the administration of medicines. One relative told us, “My family member has cream for a skin condition if they get a flare up. The staff know what to do.”

Staff kept clear records of when they had given prescribed medicines. We saw medicines were given as prescribed. Staff did regular checks of the amount of medicine in stock. This ensured that suitable stock levels were always in place, and more medicine could be ordered from the pharmacist as needed. Medicines were stored in a locked area, to prevent people accessing them unsafely. Where medicines needed to be stored at a certain temperature, this had been done. Staff had checked the fridge temperature daily to ensure it was working as expected.

Staff had received training on how to administer medicines safely. The management team had regularly assessed staff competency, to ensure they were following best practice.

The medicines administration records file contained records for people living at the adjoining service, along with the people living at Clarendon Court Nursing Home. We discussed this confusion around documentation with the deputy manager and registered manager. They arranged to review their recording systems, to ensure this related only to the people living at this service.