Cofton Park Manor Care Home Also known as Cofton Park Manor Care 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. This is the first assessment for this newly registeredservice. This key question has been ratedGood.This meant people were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a culture that supported an approach to care that was safe and focussed on the people in the service. The people using the service, relatives and professionals felt the management were open and honest. Concerns and incidents were reviewed and lessons learnt to improve and embed good practice. People felt confident in being able to raise concerns and were reassured the provider and management team were proactive in listening, responding to and then learning from any concerns. We found the manager responded to and acted upon the actions we identified during the inspection,and the provider had quickly taken on improvements and embedded them into the wider systems and processes.

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. Initial assessments included the involvement of the people themselves as well as their relatives. Key information about people’s needs and wishes was available for health professionals to ensure people received continuity of care and safely transition between services.

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,however during the inspection we identified a concern which had not been considered for safeguarding. Action had been taken by the manager to address the concern and it was clear from the records the person had not wished for it to be safeguarded, however due to the nature of the concern we identified that the local safeguarding team should have been contacted. The management team reflected on this, agreed and contacted the local safeguarding team retrospectively. Whilst it did not meet the threshold for a safeguarding referral, consideration was still needed at the time of the concern. We felt assured this was an isolated incident and found other concerns and accidents had been safeguarded appropriately.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe,supportiveand enabled people to do the things that mattered to them.There was a clear approach by staff to keep people safe and respond to risks. People with impaired mobility were supported safely to engage with activities and opportunities in the service and risk assessments and staff knowledge contributed to how risks were managed and mitigated.There was a focus from the management and clinical team to ensure risk assessments were reviewed when needed. One member of staff toldus“It is about supporting people here, not doing everything for them it is our job to enable them as much as we can, safely.”

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 environment was purpose built to the needs of the people in the service and was clean and spacious. We found equipment was in good order and the environment wellmaintainedand kept in good order both by the management team and by staff who took care and pride in creating a safe and homely environment.

The provider made sure there were enough qualified,skilledand experienced staff, who received effective support,supervisionand development. They worked together well to provide safe carewhichmet people’s individual needs.People told us there were always staff around to see to their needs. We found when people alerted staff to a need forassistancestaff were quick to respond. We were assured there were enough staff to ensure the delivery of safe and effective care through both the day and night.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns withappropriate agenciespromptly.There were effective infection prevention and control policies and procedures in place.Weobservedstaff follow good practicein infection control, the environment was clean and kept hygienic.

The provider made sure that medicines and treatments were safe and met people’s needs,capacitiesand preferences. Staff involved people in planning, including when changes happened.Medicines were stored and managed safely. Only staff who had relevant medicines competencies were able to administer medicines. Medicines records wereaccurateand reflective of what had been administered. Where people need asrequired‘PRN’ medicines thisappeared to beadministered in line with their prescribed needs.However,we found where people were prescribed PRN medicines for pain relief there was no system of pain scoring meaning we could not be sure how staff knew when aperson’spain required medicines. We were assured staff were asking people if they were in pain but could not be assured of a consistent approach to how todetermineif pain relief wasrequired. Once we raised this,the clinical teamimmediatelystarted to review tools and resources toassistwith measuring and recording pain when people experienced this to enable more effective administration of PRN medicines.