Tapton Grove

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 inadequate. At this assessment the rating 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 how people’s medicines were managed.

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 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 identify and embed good practice. The provider had made improvements in developing a more positive and proactive safety culture. We found that learning from incidents was beginning to be embedded and we saw examples where risks had been identified and addressed promptly. Improvements had also been made to environmental safety. Hazardous substances were now stored securely in line with Control of Substances Hazardous to Health (COSHH) requirements, food safety practices had strengthened, and equipment such as broken window latches had been repaired to reduce risk.

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 made improvements in how they worked with people and external partners to support safer and more consistent care. Systems for managing and monitoring safety had strengthened, and staff told us they now received clearer information during shift handovers. Improvements had been made to how known risks were managed. People’s care plans and risk assessments had been reviewed since our last inspection, and we found appropriate control measures in place to reduce the risk of avoidable harm.

We found that the provider had strengthened their systems and processes, and effective measures were now in place to ensure accidents and incidents were properly investigated and analysed. The registered manager had taken appropriate action when safeguarding concerns arose, including fulfilling their duty of candour and reporting matters to external bodies such as the local safeguarding team. Care plans and risk assessments had been updated following safeguarding incidents, and we noted improvements in how staff recorded people’s choices regarding their personal care. Staff spoke positively about the changes the provider had introduced, including clearer routes for escalating any concerns to the registered manager and provider. We found staff were up to date with their safeguarding training, and the provider had also arranged workshops to strengthen staff understanding of how to record incidents accurately to ensure appropriate action could be taken. People told us the service was safe. One person told us, “I feel safe living at Tapton Grove, the staff ask me when I am going out and when I will be coming back the fact that the doors are coded makes me feel safe” and another person told us, “Tapton Grove, it’s nice having the staff around and to be able to lock your own door I have never felt unsafe.”

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. Improvements had been made to how known risks were managed. People’s care plans and risk assessments had been reviewed since our last inspection, and we found appropriate control measures in place to reduce the risk of avoidable harm. Staff now had access to clear information on how to manage risks identified by the provider and external agencies, and this was reviewed and updated when people’s needs changed. We did, however, find some wording in care plans that could be more concise in distinguishing between current and historical risks. People confirmed they had opportunities to be involved in planning their care. One person told us, “I have been involved in my care planning for the future and have been involved in setting goals for myself this has been working well for me”. Relatives spoke positively about the support their family members received. They told us staff kept them regularly informed and involved in their family member’s care.

The provider detected and controlled potential risks in the care environment. They ensured equipment, facilities and technology supported the delivery of safe care. Improvements had been made to the management of environmental risks since our last inspection, including regular checks of the service to ensure it remained safe and any hazards were identified and addressed promptly. Safe systems were now in place to oversee access to the service and reduce the risk of people subject to Deprivation of Liberty Safeguards (DoLS) leaving the building unnoticed. Risks previously identified had been mitigated. People could now access the kitchen safely, COSHH products were stored securely, and furniture had been fixed to walls. Broken window latches had been repaired, and issues relating to trailing cables and overloaded plug sockets had been resolved. We did however, identify some items stored on top of wardrobes we asked the provider to assess the risk this presented.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked well together to provide safe care that met people’s individual needs. The provider had reviewed the staffing structure and increased the number of nursing staff. They had also recruited permanent staff, reducing reliance on agency workers. Staff spoke positively about these changes. One staff member told us, “There were staffing issues previously but that’s much better now. Feels more comfortable and is running smoothly”. We found staff had received training appropriate to their roles, and systems were in place to ensure they had regular opportunities to meet with the management team, both in groups and one to one, to discuss concerns, reflections and their professional development needs.

The provider assessed and managed the risk of infection. Improvements had been made to infection prevention and control systems, and we found safe arrangements in place for food storage. The cleanliness of the service had been addressed, and people were now able to access the kitchen safely. The provider carried out regular audits in these areas, and we observed staff following the measures in place.

The provider did not always ensure medicines and treatments were managed safely. Although the provider had introduced new systems, they were not consistently effective. Some medicines had not been dated when opened, and we found an expired medicine was still in use. This was unsafe practice and placed people at risk of exposure to expired medicine, which may no longer be safe or effective. This meant safe medicines management processes were not being consistently followed. There was no system for staff to record the outcome of PRN (when required) medicines, including whether they had been effective. This meant the provider could not be assured that people’s symptoms were being monitored or responded to appropriately. In addition, the provider’s policy required staff to remove discontinued medicines from pharmacy‑prepared blister packs, increasing the risk of errors. The provider’s systems to audit medicines had not identified these issues and this placed people at risk of receiving their medicines incorrectly.