Chapel Garth EMI Residential 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 remained good. This meant people were safe and protected from avoidable harm.

This service scored 62 (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. Accidents and incidents were recorded and showed initial actions taken but there was no analysis or evidence of improvement to practice. We spoke with the manager who told us they were planning to devise a system to ensure lessons were learnt. The provider told us that the senior management team had systems and processes in place to ensure safety events were analysed and actions taken. However, some improvement was required to ensure the management team in the home understood the process and could contribute to 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 provider had a process in place to support people who transferred to other providers, such as for a hospital stay, to ensure all appropriate information was sent with the person. This included their life history, medical condition, current medication and care plan summary.

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. The provider had a safeguarding policy and staff received training to ensure they could recognise and report abuse as required. A safeguarding guide was available in each staff personal file. This set out what abuse is and how to respond to it, types of abuse and contact details to raise concerns with professionals such as safeguarding in the local authority.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, whether appropriate legal authorisations were in place, when needed, to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. The manager maintained a record of DoLS and care plans included information about mental capacity.

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. For example, we saw a risk assessment in place regarding accessing the garden which highlighted potential hazards such as falling outside, poor weather, use of equipment, and to ensure pathways were clear. The outside space was not accessible, it had a high build-up of leaves, fence broken which was leaning outwards, and a handrail which required painting. Therefore, the risk assessment could not be adhered to. However, we saw some good practice when staff followed safe moving and handling practices and assisted people to relieve pressure.

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 detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Environment checks were completed in line with expected standards and records were maintained. Care documentation included Personal Emergency Evacuation Plans (PEEP's) to ensure people were supported appropriately in the event of an emergency evacuation. However, there was a build-up of leaves outside making pathways and exits difficult to access. This was addressed in a timely way.

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. The provider had a recruitment system which assisted them in the safe recruitment of staff. The provider completed pre-employment checks such as references and Disclosure and Barring Service (DBS) checks. DBS checks provide information including details about convictions and cautions held on the Police National Computer. This information helps employers make safer recruitment decisions. Whilst there appeared to be sufficient numbers of staff available, they needed to be deployed more effectively. The provider was aware of this and were taking action to resolve it.Staff told us they received training, mainly via eLearning. Staff required further training to understand dementia care. The manager had previously identified this learning need and was in the process of arranging face to face training for staff.

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 home was predominantly clean; however, we raised some minor issues with the management team. These included the lack of covers on light pulls, some flooring which required attention in 2 areas of the home, mops were not always stored correctly to minimise cross infection and laundry skips without lids were in operation. Following our site visit the management team sent us evidence these issues had been resolved or were in the process of being.

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. People predominantly received their medicines as prescribed; however we found body maps to support the application of topical creams, were not always completed, 1 stock balance was incorrect and medicines were not always store at the recommended temperature when the medicine trolly was out of the medication room for long periods of time. We raised these issues with the management team who took appropriate actions to resolve them.