Station House

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 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.

This service scored 56 (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.

The provider had systems in place for staff to record any accidents and incidents. Overall, managers reviewed and investigated these, and consideration was given to whether further actions were needed. However, for one person, whilst staff had acted in response to aspects of risk, they had not completed some incident forms as required.

Learning from incidents was encouraged and shared with staff through ‘Incident Bulletins’. The registered manager was focused on supporting staff to view feedback as constructive and a way to learn and improve. Staff were responding well to this approach.

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 worked with health and social care partners to support safe and timely discharges from hospital. As well as permanent places, they provided places for assessment, recovery and rehabilitation. Multi-disciplinary staff regularly met to manage the support people needed and review their progress.

The provider had made some changes to their pre-admission assessment documentation to ensure all information obtained before people were admitted was accurate and up to date. They had implemented a lead nurse role to support the effective movement of people being admitted and discharged from the home.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always 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 always share concerns quickly and appropriately.

The provider had a safeguarding policy and procedure in place. Staff undertook relevant training and were aware of their duty to identify and report any safeguarding concerns. Staff told us, “I would report straight away, we have a whistle-blowing policy in place. Anything untoward, I would report.”

Overall, the management team ensured any safeguarding concerns were reported in line with local procedures. However, they needed to ensure procedures were robustly followed, as we found 2 issues which had not been reported as required. One related to unexplained bruising and the other to aspects of a complaint which was being dealt with internally. The registered manager ensured these were subsequently reported.

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.

Overall, staff assessed potential risks to people, and took actions to mitigate these, such as providing sensor equipment or crash mats next to people’s beds. However, in 2 cases, people’s records did not demonstrate risks had been adequately assessed and mitigated. These related to people living with dementia who may express agitation or enter other people’s private spaces. Whilst staff had taken some actions to manage any risks, these were not clearly recorded.In another case, staff had not ensured a person’s bedroom door sensor was switched on. The registered manager took action to address this straight away.

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.

Systems were in place for environmental risks to be assessed, with plans developed to mitigate any risks, such as for a small pond in the courtyard area. However, managers needed to ensure staff followed management plans robustly, as we found thickening powder used for drinks, was left unattended on a medication trolley and in a kitchenette.

The provider had a call bell system in place including sensor mats. However, we found one sensor mat wasn’t activating and staff had difficultly re-setting 2 call bells. The registered manager took immediate action to ensure all sensor mats and call bells were working effectively. The regional manager confirmed they would report the system to the provider for further review, as there were some ongoing issues. They put a system of regular checks in place ensure any issues were identified and dealt with in the meantime.

There was an outside smoking area, which was untidy with unsuitable seating. The registered manager took action to address this.

There were 2 maintenance staff who were responsible for undertaking various health and safety checks and other maintenance of the building. A range of checks were undertaken with a system in place to ensure these had been competed as required. Overall, the building was well maintained and decorated, ongoing re-painting was in-progress.

The provider did not always make sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development.

Feedback indicated there were enough staff to support people safely. Comments included, “Always plenty of staff about” and “We have enough staff.” The provider used a tool based on people’s needs to assess the staffing levels required. Staff told us, “It’s enough staff, each day varies, in general it’s a good number to have” and “The staffing levels are okay, they will always get cover for sickness.”

Staff undertook induction and ongoing refresher training. They told us they received appropriate training, however, some feedback suggested more practical training may be of benefit for certain topics. The registered manager kept a training matrix to oversee training, and where some staff were overdue, timescales had been issued for completion. Further training in specific areas was planned.

Staff received some training in relation to supporting autistic people and people with a learning disability. However, the correct level of training had not been provided in line with current requirements. Also, whilst nurses undertook training in relation to epilepsy, this had not been offered to care staff. Following our feedback the registered manager confirmed this training had now been arranged.

Staff told us they felt supported and were offered supervision meetings and received performance reviews. The provider had a “Performance Management Cycle” which guided managers to offer reviews and one to one meetings over a 12-month cycle. However, records showed that whilst staff had received various support meetings, these had not always been carried out fully in line with the policy.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The service was clean and domestic staff followed cleaning schedules. The management team had been working on an action plan following an external infection prevention and control (IPC) audit.

On the first day of our assessment, staff did not always follow the correct procedures for the use of PPE. The management team took action to ensure staff were reminded about the correct procedures. Monitoring the use of PPE, was added to their overall action plan and they contacted the local infection IPC team to arrange further staff training.

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.

Overall, the provider had systems in place to ensure people received their medicines as prescribed. The management team undertook audits and had made some recent improvements to ensure people always received their medicines at the right time, especially where they were time specific. They were improving protocols used to guide staff about administering “as required” medicines, to ensure they were sufficiently detailed.

We found staff had not always recorded the date of opening of some medicines such as eyedrops, this is important to ensure items do not become out of date.

During our assessment, a staff member did not fully follow procedures relating to the security of the medication trolley and keys. The management team addressed this immediately.