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 requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

The service was previously in breach of legal regulation in relation to safe care and treatment. Improvements were found at this assessment, and the service was no longer in breach of this regulation.

This service scored 72 (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 understood the importance of raising concerns and were able to describe how safety incidents, accidents and safeguarding concerns were reported, investigated and reviewed. Records, including meeting minutes and lessons learned documentation, demonstrated learning from incidents and safeguarding concerns was discussed with staff and used to help drive improvements.

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 registered manager worked well with health and social care professionals to ensure people received the care and support they needed. People and their relatives told us they had good access to GPs and other health professionals, and care plans included relevant assessments and clinical guidance. A relative said, “Staff will always call the doctor if needed. [Family member] is treated with care and compassion.”

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 and relatives reported they or their family members felt safe living at Seven Arches Nursing Home. A person told us, “I feel safe here.” And their relative visiting added, “I feel safe them being here, lovely people, it is great here, smashing place.”

Staff had received training in safeguarding and understood how to report concerns. A staff member told us, “I have safeguarding training and understand the signs of abuse. If I had any concerns, I would report to the nurse in charge and manager straight away and record it. I know it can also be reported to the local authority or CQC if needed. I am also encouraged to speak up through the whistleblowing policy.”

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). At the time of inspection, where appropriate, people had authorisations in place and any conditions in place as part of the authorisation were met.

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. However, record keeping related to risk required improvement to ensure current risk was updated in all sections of the care plan.

Individual and environmental risks were identified, assessed and managed to help keep people safe. Improvements had been made in areas previously identified as requiring attention, including the management of fluid monitoring and repositioning. Where people required monitoring or specialist equipment to reduce identified risks, these arrangements were clearly documented and subject to regular review.

However, although staff had updated risk assessments and risk management information, some outdated information remained in other sections of people's care plans. This created a risk that staff, particularly those unfamiliar with the person, may not always have access to accurate and consistent information. For example, 1 person had previously had a bedrail in place, however following review this was no longer appropriate, but not all parts of the care plan had been updated. This meant there was a risk an unfamiliar member of staff could incorrectly raise the bedrails, potentially restricting the person's movement and increasing the risk of harm.

The registered manager acknowledged this issue and told us they would undertake a review to ensure all sections of care plans were updated and reflected current risk management strategies.

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 equipment used to support people, including hoists, were serviced and inspected in line with regulatory requirements. Fire safety systems were appropriately managed, with weekly fire alarm testing, and regular checks of fire safety equipment. Water safety monitoring and testing were completed to reduce the risk of harmful bacterial growth.

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.

People and relatives spoke positively about staffing levels, with 1 person telling us, “I like it here, there is plenty of staff.” A relative told us, “There are enough staff in the lounge area and enough staff to deal with what is there. There is good interaction (with the residents).”

During our inspection, we observed people received timely support and staff responded promptly to requests for assistance. Staff also told us staffing levels were adequate. A member of staff said, “I don’t feel we have any staff shortages. We have enough staff and we are happy with that.”

Staff received appropriate training and support to carry out their roles effectively. Training records demonstrated staff completed mandatory and role-specific training, and staff told us they had opportunities to develop their knowledge and skills. A staff member said, “Every employee at Seven Arches is adequately trained both offline and online. Because of it, I am able to study more and work more efficiently. Every year, I am required to attend training. I was given face-to-face training on catheter maintenance and challenging behaviour.”

Recruitment processes were robust and included the necessary pre-employment checks to help ensure staff were suitable to work with vulnerable 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.

Since the last inspection significant improvements had been made to infection control and cleanliness at the service. The provider had replaced equipment such as bed rail protectors and increased levels of cleaning carried out. There was now a deep clean carried out twice a month and regular daily routine cleaning was being completed. Audits were picking up minor issues and action was taken to rectify these.

We did feedback some minor issues of tap descaling noted during our visit which the registered manager was following up.

People and relatives were positive about the cleanliness in the home. A relative said, “The home always looks clean with no smells, nice, pleasant environment.”

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 told us they received their medicines when needed and at the correct times. Medicines were administered by trained and competent staff and stored safely in line with manufacturers’ guidance. The reconciliation of medicines had improved since the previous inspection, and staff were checking this regularly. A relative said, “[Family member] gets their medicines on time and staff wait to ensure they take them.”

Some people were prescribed medicines on an ‘as required’ (PRN) basis. PRN protocols provided clear guidance for staff to ensure medicines were administered correctly.