Summerfield Court

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.

The service was in breach of legal regulation in relation to safeguarding.

This service scored 50 (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.

We found incidents and accidents were recorded, however, we found examples where this information had not been used to update a person’s risk assessments and care plans.

We reviewed the provider’s analysis of accidents and incidents and identified a high number of recorded restrictive practices. This had not been identified by the management team prior to our inspection. After we raised concerns, the provider investigated and advised this was due to recording issues.

Audits completed by the provider had identified concerns in relation to finances, restrictive practices, and incident management. However, actions taken were not always timely or effective, and we continued to find these issues during our assessment.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

While people had access to healthcare professionals and staff sought support from external agencies when concerns arose, we found examples of poor coordination between those supporting people.One healthcare professional told us, “Staff receive advice well however it is not consistently implemented. Therapy resources and programmes are not always available on subsequent visits or have clearly not been implemented since provision.”

Some people had experienced changes in their care needs, we could not find clear evidence that risks were reassessed or that care plans were updated to reflect changed circumstances.

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

People were not always protected from the risk of abuse and neglect. We found examples where the safeguarding policies and procedures had not always been followed. People's finances were not well managed, and we asked the provider to raise a safeguarding in relation to people’s finances. After this was raised, the provider took action to address concerns and to improve the systems of oversight in this area.

Staff were trained in safeguarding people; however, we found this had not always been effective. In our conversations with staff, they showed inconsistent understanding on how to keep people safe from abuse and how to whistleblowing if they wanted to escalate concerns further.

Some people had restrictions in place as part of their care and records did not show how decisions had been made in people's best interests or why it was proportionate for restrictions to continue. We also found the provider was not fully compliant with conditions on people’s deprivation of liberty safeguards orders (DoLS). The provider started working on these issues after we raised them.

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.

Some people had risks to their health, safety, and well-being that were well managed in practice; however, records did not always reflect this. We found examples where risk assessments were missing, incomplete, or out of date for known risks such as falls and epilepsy. People were not consistently involved in discussions about how risks were managed or reviewed.

The provider did not always detect and control all potential risks in the care environment.

The premises were generally clean, well-maintained, and suitable for the people living there. Equipment checks, including moving and handling equipment and health and safety certificates, were up to date.

Overall fire safety was well managed, but we found examples where people’s personal evacuation planswere either not detailed or easy to access.

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

supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Although staff had received mandatory and additional training to provide safe and person-centred care to people, we found this training had not always been effective in how care was delivered and in staff’s knowledge. For example, staff showed inconsistent knowledge about safeguarding, whistleblowing procedures and management of some risks. Feedback from healthcare professionals about staff’s knowledge and skills was also inconsistent. Their comments included, “I am concerned by the lack of staff knowledge of residents input/interactions and the team involved with their care” and “I have witnessed the team provide a quick response to address this person’s concerns.”

The provider’s supervision and appraisal matrix showed staff were offered regular support with one to one meetings and staff told us they felt well supported. Recruitment was managed safely.

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 environment was clean, and staff demonstrated appropriate infection control practices during our visits. People told us the home was clean.

External infection prevention and control audits showed a high level of compliance.

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.

Overall, medication was well managed, we did not find medication errors. However, some areas of recording needed improvement such as protocols for people who required ‘as and when’ required medication and the application of creams. We also found one person had been assessed as able to self-administer their medication, however they were not being supported to gain independent in this area. We shared our concerns with the provider and during our second visit, we found actions had been taken and there were improvements.