Stambridge Meadows 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 service under a new provider. This key question has been rated 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 people’s safe care and treatment.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff listened to concerns about safety and investigated and reported safety events. Safety incidents were appropriately investigated by the management team. Where risks were identified, these were documented, and the service worked with people to improve their safety, for example by considering what equipment could support them. There was a positive culture of learning from safety events. We saw evidence the registered manager analysed incidents, falls, and near misses, and that the lessons learned were shared with staff at the most recent staff meeting.

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. A persons relative told us, “[Relatives] transition from hospital to the home was really smooth and [relative] settled in quickly.”

The registered manager completed pre-admission assessments with people prior to them moving into the service. Detailed information was gathered to ensure the service could meet people’s needs and provide appropriate support. This information was recorded and shared with staff through each person’s care plan.

People were supported to access healthcare services when required, and systems were in place to ensure essential information was shared in the event of an emergency. For example, hospital passports were readily available to staff if a person needed to attend the hospital.
 

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 people we spoke with all said they felt safe living at the service. When asked if they felt safe, 1 person told us, “Oh yes, the carers are all very, very good.” Relatives also shared they felt confident their loved ones were safe. Comments included, “I am confident that [relative] is safe and much safer than if they were still living at home,” and “I’m really happy with [relative’s] care, absolutely. [Relative] is safe and well cared for.”

Staff were able to tell us about the different types of abuse and could describe what they would do to protect people if they had concerns. Training records showed that all staff members had completed safeguarding training, with senior staff also having completed Level 3 safeguarding training.

The service had safeguarding systems and processes in place to protect people from abuse. The registered manager described efforts to develop a positive and open safeguarding culture, where staff felt confident to share concerns. This included regular staff meetings and supervisions, an open-door approach, and ensuring staff had direct contact details for the management team. The registered manager was aware of their responsibility to notify us and the local authority of any allegations or incidents of abuse.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found the registered manager understood their responsibility to make DoLS applications when required and did this in conjunction with people’s relatives and advocates.

The provider worked with people to understand risks by thinking holistically. However, staff did not always provide care in a way that ensured people’s needs were met safely and people were not consistently supported to manage identified risks effectively. Although risks had been identified and assessed, there was not always evidence the service had followed its own risk management strategies. Records did not consistently show whether support required to reduce risks had been completed or documented, so we could not be assured people received the appropriate level of support. In response, the provider told us some risk mitigation measures were no longer required. This highlighted the need for assessments and risk assessments to be reviewed and updated to ensure they remain accurate and relevant.

The provider did not always detect and control potential risks in the care environment. The registered manager was taking steps to make improvements to the environment. A new lift had been installed to support people’s mobility and access throughout the building, and work was underway to improve the décor to ensure the environment was more suitable and comfortable for people. Improvements to fire safety arrangements were also being progressed, and appropriate fire protection measures were in place at the time of the assessment.However, environmental risks were not fully managed. The provider had not effectively controlled the risk associated with access to hot water. We found several taps delivered water at temperatures exceeding 44 degrees Celsius, which posed a risk of scalding. This placed people at potential risk of harm, and appropriate controls to manage this risk had not been fully implemented. The registered manager took prompt action to protect people from this risk when it was raised during the assessment.

The provider made sure there were enough qualified, skilled and experienced staff, and staff received appropriate support, supervision and opportunities for development. There were robust recruitment practices for the service’s own staff, ensuring they were suitably experienced, competent and safe to work with people before starting their roles. Recruitment checks included full employment histories, suitable references and proof of identity. All staff employed directly by the service had completed Disclosure and Barring Service (DBS) checks prior to commencing employment. The DBS helps employers make safer recruitment decisions and helps prevent unsuitable people from working with people who use care and support services.

Although appropriate recruitment checks had been completed for permanent staff, records had not been consistently updated or verified for all agency staff. Some agency profiles were outdated, with missing or undated information on training and recruitment checks, limiting assurance these remained current. The registered manager took prompt action to address this when identified.
 

The provider did not appropriately assess or manage the risk of infection. They failed to identify and control the potential for infection to spread and did not ensure that suitable and effective policies and procedures were in place for the management of specific infection control risks.

The home appeared clean and tidy, and staff maintained accurate and up‑to‑date records of cleaning routines, including within the kitchen where no hygiene concerns were identified. However, risks relating to infection, specifically legionella water management, were not effectively managed. The provider could not provide sufficient assurances people had been protected and infection risks had been managed safely or appropriately.
 

The provider ensured that medicines and treatments were generally managed safely and met people’s needs, capacities and preferences. People were supported to take their medicines at the appropriate times; with the level of support they required.Staff responsible for administering medicines had received appropriate medicines training, and the management team had completed competency assessments with staff involved in medicines administration. The registered manager was taking steps to improve medicines management and had identified areas requiring improvement, particularly in relation to the clarity of medicines directions. During our visit, the registered manager was working in conjunction with the GP to address these issues.

PRN (as required) medicine protocols were in place; however, these did not always contain sufficient detail to ensure safe and consistent administration. For example, one protocol stated that it was for when the person was “agitated” but had no information on how the agitation presented itself. In addition to this, several PRN protocols did not include a review date. These gaps meant staff were not always provided with clear guidance to support safe decision making when administering PRN medicines.