Saxondale 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 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 legal regulation in relation to the management of risk.

This service scored 47 (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 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. Policies and procedures were in place but were not effectively followed or implemented. For example, records we viewed did not consistently show there was a proactive culture in place regarding safety incidents or concerns and that these had been effectively reflected upon and used to drive improvement.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They 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.

Staff and managers told us information from peoples care plans and medication administration records were collated and shared at the point a person needs to move services, for example to visit hospital. However, during the inspection issues were identified with the level of accurate and up to date information in peoples written records. This placed people at potential risk of harm.

Professionals who visit the service told us information was not always shared consistently or in a timely manner. Some issues were also raised in regard to the accuracy of documented information in peoples care plans.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not 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 share concerns quickly and appropriately. For example, where people had experienced harm or made allegations of abuse this had not been reported to the local authority safeguarding team. Records showed while some concerns of a safeguarding nature had been raised with the local authority as required, there were incidents where advice should have been sought to ensure people were fully protected. Failing to recognise potential safeguarding concerns and escalating these appropriately placed people at increased risk of harm. Some people and relatives told us they felt people were safe at the service.

Staff spoken with were able to recognise signs of abuse and knew how to report such concerns.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. At the last inspection risks to people’s health and safety were not always being assessed. At this assessment we found systems and processes had not improved sufficiently. Risks associated with people's care were not always identified and actions had not always been taken to mitigate risks. Some people required risk assessments, but these were not always in place to ensure people's needs were met in a safe way.

Where people were at risk of falls, risk assessments were in place and staff were allocated to monitor people. However, some people were observed to not be wearing appropriate footwear, which may place them at an increased risk of falling. For other people who were at increased risk of skin damage, we found gaps in records relating to people’s pressure area care, meaning we couldn't be assured people were receiving repositioning as required. Failure to assess, monitor and mitigate these risks meant people did not always receive safe care and treatment.

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. People told us they felt safe and did not raise concerns about the environment. However, relatives commented about the difficulty getting in and out of the building.

Managers told us they were in the process of developing a plan to improve maintenance of the buildings. The service had many areas that were worn and in a general state of disrepair. Redecoration was needed in many areas where walls had been damaged and were in the process of repair.

The home had minimal signage to assist people to navigate around the home. Some bedroom doors did not have people's names on them, and bathroom and toilet doors signs were not dementia friendly. We saw a lack of pictures and stimulus available throughout the home. For example, communal areas of the home were sparse and lacking in things for people to engage with. We discussed these issues with the managers who assured us action would be taken to address these concerns. On the second day of the assessment, we found work had started to make the home more dementia friendly.

The service was in the process of implementing new management and developing a maintenance plan to prioritise required actions. This improvement will take time to embed.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs. The manager used a dependency tool to determine the numbers of staff required to meet people’s needs. This was kept under review, so people’s current and changing needs were met. Staff at the service told us they felt the service was understaffed and this had a negative impact on care delivery. Although staff told us they felt managers were approachable, they did not feel their concerns in this area had been acted upon. One staff member said. “We are struggling for staff and staff have told them [management team].” Throughout the inspection staff were busy with care tasks. They had very little opportunity to spend any meaningful time with people or ensure their safety. There were times when people at risk of falls were left unattended for long periods of time. Staff were safely recruited, and a programme of training was provided to enable them to carry out their role and responsibilities.

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. Staff told us personal protective equipment (PPE) and all cleaning materials needed were available. They confirmed they had received infection control training.

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. Medicines were stored safely and securely. There was a process in place for training new staff and a signing-off process for medication administration in addition to annual competencies. There were regular audits of people’s medicines.