Seven Arches 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. At our last assessment we rated this key question good. At this assessment the rating has changed to 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 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.

Safety concerns had been identified during this assessment which had not been picked up and actioned by staff or the provider. This meant we were not assured processes in place to investigate and report safety concerns were robust. Improvements were needed to support staff to identify and action safety concerns more effectively.

The provider did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

During the assessment we identified 1 person recently discharged from hospital, risks to their care and support had not been fully mitigated or explored following their admission to the service. The person had been discharged with a restriction in place which staff had not explored with the hospital about the reason for this. Risks to this person’s care and support had not been fully assessed. The registered manager took immediate action following our feedback.

The provider had processes in place to raise and share concerns with partner agencies. Some further learning was required to ensure processes were robust.

On a review of accidents and incidents we identified 2 incidents which potentially met the threshold for a safeguarding referral. The incidents had been investigated and appropriate action taken, however the provider had not explored fully if these incidents required a referral to the local authority safeguarding team for investigation. On the second day of our assessment the registered manager had organised a call with the local safeguarding team to further explore the threshold as to which incident referrals would or would not meet their criteria.

People and relatives told us they or their family member felt safe with staff. One person told us, “I feel safe, absolutely. They make me feel safe by coming to see if I am ok.” A relative said, “Yes, 100% I know my [family member] is safe.”

Staff had received safeguarding training and were aware of safeguarding and whistleblowing policies. A staff member told us, “If I suspect a resident is at risk of harm or abuse, I will make sure, the resident is safe and would report it immediately to the senior carer or nurse in charge. If necessary, I would escalate the concern to the safeguarding lead or external authorities.”

The provider did not always work well with people to understand and manage risks. Systems in place required improvement to fully identify and mitigate risks to people’s care and support.

Risk to people had not always been fully explored. We identified 3 people with bedrails who also had crash mats beside their bed which indicated they may be at risk of falls from the bed. We brought this to the attention of the registered manager who immediately reviewed their care and support, and the crash mats were removed. Care plans in place were confusing related to risk and did not always explain or explore fully why crash mats were needed if bedrails were in place.

Clinical risk was not always monitored effectively. Monitoring charts such as fluid and repositioning were not routinely checked to explore any shortfalls so concerns could be picked up quickly and escalated if required. Following our feedback the registered manager took action to ensure these charts were monitored daily.

Thickening powder used in drinks for 1 person was left on their bedside table. This powder is a risk to people if ingested or swallowed. The registered manager immediately removed this to the locked clinical room until the person was provided with a locked drawer or cupboard.

Staff told us there were processes in place such as handover sessions to update them in relation to risk. A staff member told us, “Nurses and the managers tell us this in handover, we also have notes to check.”

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.

During the assessment we identified some wardrobes had not been secured to the wall which could pose a risk to people. An open staircase had not been fully assessed to identify any potential risks to people walking in the service. Damage to an electrical socket and wardrobe door was also found. The registered manager responded immediately to these concerns and action had been taken by the second day of our assessment to remedy all concerns.

Some areas of the service had been redecorated but other areas still required work. A schedule of works was in place which identified the timescales when all works would be completed.

Other environmental risks were checked regularly such as electrical, gas, water and fire risks.

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.

Throughout our assessment we saw staff were available to respond to people’s needs and they responded promptly. People we spoke with confirmed this. A person told us, “They come quickly.” Another person said, “The buzzer, yes, they do come.”

Staff were required to regularly refresh their training and were positive about the training and support they received. A staff member told us, “I did all the training here, online and practical.

The nurses do my competency checks.” Another staff member said, “We have supervision regularly and I feel supported.”

Recruitment processes were effective and ensured checks were carried out to determine the suitability of staff before they started working in the service.

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.

Whilst cleaning schedules were in place, these and infection control audits had not picked up concerns we found during this assessment. We found equipment such as bedrail bumpers and crash mats were soiled and damaged, toilet brushes sat in water which could promote bacteria growth and poor hygiene practices. Some foot operated bins were faulty and required replacing as did some overbed tables. Hoist slings were left in bathrooms over bath chairs, increasing the risk of cross contamination.

However, by the second day of our assessment a full deep clean had been carried out and all damaged equipment replaced.

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

We undertook a count of some people’s boxed medicines to check they matched the stock recorded on the medicine administration records (MAR’S). We found discrepancies on 2 occasions with other medicines hard to reconcile as a brought forward amount had not been recorded. There was no action recorded to identify these discrepancies. We also found protocols in place to guide staff when to administer ‘when required’ medicines were missing.

MAR records we viewed were signed and no gaps were found, and medicines were stored in accordance with manufacturers guidelines.

Following the assessment the registered manager told us they had resolved the discrepancies and replaced the protocols. They also added they would be changing to an electronic medicine system at the end of the month.