Selly Park

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 requires improvement. At this assessment the rating has changed to good.

This meant people were safe and protected from avoidable harm.

This service scored 66 (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.

People were supported by a group of staff who understood the actions to take in response to accidents and incidents. A member of staff told us, “When you see these things, you know you need to get it on [the system] quickly [to ensure it is acted on].” The registered manager encouraged an open and transparent working environment where staff felt able to raise any concerns they may have knowing they would be acted on appropriately.

Systems were in place to look at accidents and incidents which were analysed for any lessons to be learnt. For example, following an incident involving unexplained bruising to a person using the service, action was taken to identify the cause and put additional checks in place to reduce the risk of reoccurrence. This information and the lessons learnt from this incident were shared with all staff.

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.

Systems were in place to ensure information was passed onto staff in a timely manner through daily handovers and heads of department meetings. Staff told us communication was good and they were kept informed of any changes in people’s needs. For example, where a person had been admitted to hospital, staff were provided with updates on their wellbeing and changes to medication ready for their return to Selly Park.

People described receiving support from staff who were knowledgeable about their needs and proactive in seeking assistance from healthcare professionals when necessary. This helped ensure healthcare concerns were responded to promptly. One person told us, “If you wanted any help, they [staff] will ring them [healthcare professional] for you.”

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.

Where safeguarding concerns were identified, these were appropriately investigated, reported, and followed up with actions taken where necessary. For example, following a medication error, a full investigation was completed. The staff member involved undertook reflective practice and completed refresher training before being authorised to administer medication again.

Staff had received training on recognising the signs of potential abuse and were able to clearly explain the actions they would take if they suspected that a person was at risk of harm or abuse.

People told us they felt safe being supported by a group of staff who, they told us, knew them well. One person told us, “I get on with everybody [staff]. I love life. I find the staff very good.” and another said, “The staff are ok and very helpful. I have no problems with the staff – I get on well with them.” A relative told us, “I feel [person] is safe. I haven’t seen anything to say [person] has been neglected.”

Systems were in place to ensure appropriate applications were made for Deprivation of Liberty Safeguard (DoLS) authorisations and this was only used when in the best interests of the individual. Where 1 person had conditions in place on their DoLS authorisation, we saw these were being adhered to. However, not all staff spoken with fully understood what DoLS meant for the people living at the service and the potential implications on delivery care. We spoke with nominated individual about this who told us they had identified this gap in staff’s understanding and plans were underway to address this.

Relatives spoken with confirmed they were kept informed of any events or concerns of their loved ones.

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.

People told us they were supported by staff who knew them well and understood the risks associated with their care and support needs. However, we found care records did not consistently reflect all identified risks to people and how to manage those risks. For example, 1 person's care records did not contain a care plan or risk assessment relating to a specific aspect of their care. We also found that a person who was unable to independently use a call bell did not have a corresponding risk assessment in place, despite similar assessments having been completed for other people with comparable needs. This demonstrated that risk management processes were not always applied consistently.

The registered manager took immediate action to address these concerns when they were bought to their attention.

Staff told us that the care records available provided them with the information they needed to deliver safe and effective care. For example, where 1 person was at risk of choking, staff were able to describe the actions taken to reduce the risk. One staff member explained, “We have to make sure [person] is sat upright, assist them very slowly or they can start coughing. We are always aware of the ‘soft signs’ if someone doesn’t look right or have a temperature or non-stop coughing – we would let the nurses know of any changes.” The registered manager had taken steps to strengthen the clinical oversight arrangements and weekly clinical risk meetings had been introduced, alongside a clinical risk register designed to support the identification, monitoring and management of emerging risks. These measures were intended to provide greater oversight of people's changing needs and ensure timely action was taken where concerns were identified.

People were supported by a group of staff, many of whom had worked at the service for many years and knew them well. Staff were able to describe the risks to people and how they would manage those risks when supporting them with their care.

We saw people were involved in the development of their care plans and positive risk taking, for example, ensuring people were provided with the most up to date information regarding their current health care needs when making a decision that could potentially have a negative impact on their health.

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.

People told us they felt safe in their living environment and we saw arrangements to monitor the upkeep and safety of the premises were in place. However, a number of environmental concerns were raised during the inspection which the provider’s own audits had failed to identify. For example, a magnetic door holder had come away from a fire door, and information relating to fire safety zones was missing in people’s Personal Emergency Evacuation Plans (PEEPs). The registered manager addressed these concerns immediately.

We inspected the service during a heatwave. We noted people had access to fans in their rooms and communal areas and people were encouraged to drink more fluids. People and staff all told us every effort had been made to keep them cool and comfortable during the hot weather. However, it was noted on the 3rd day of the inspection, during the hot weather that some radiators had come on as staff were trying to get the hot water working. This was due to the current boiler system but had not been flagged as a potential issue in the heatwave action plan. This was immediately raised with the registered manager and action was taken to address this.

A range of systems and processes were in place to monitor environmental safety and help ensure health and safety requirements were met. Routine maintenance checks were taking place ensuring the safety and upkeep of the environment. Daily management walk-rounds of the building ensured any issues identified were shared with the member of staff responsible for maintenance of the building at the daily ‘heads of department’ meetings.

We saw appropriate use of signage throughout the building, both pictorial and in braille, to assist people when navigating their way around the home. However, it was noted the use of some decoration in the home may lead to increased risk, frustration and confusion amongst service users, and particularly those living with dementia. For example, a ground-floor alcove had been decorated as a library with a hoist in situ, which may create a trip hazard or confusion.

The provider did not always make sure staff recruitment processes were robust and staff did not regularly have their competencies assessed.

People were supported by a consistent group of staff, many of whom had worked at the service for several years. Recruitment processes were in place to ensure people were supported by staff who had been safely recruited.

New personnel files had been developed; however, these were not always consistently robust. For example, for 1 individual, a reference had been received and accepted, but it did not match the referee named on the application form. For 2 other individuals, online Disclosure and Barring Service (DBS) checks had been completed; however, the DBS certificates had not been seen. In another case, further recruitment documentation was incomplete. Actions were taken by the registered manager to address the discrepancies found on inspection. Staff were supported to develop their skills and take on lead roles, which they clearly enjoyed. One member of staff told us, “I enjoyed the additional training and the manager supports me”. Staff competency assessments were in the process of being rolled out.

People told us they considered there to be enough staff to meet their needs and had no concerns about staffing levels. One person said, “It never worries me – if I really needed help from staff, someone would come” and another commented, “Yes, they [staff] are normally here pretty quickly [in response to call bell], but you have to realise lots of people needs lots of different things. I have no complaints.”

Staff confirmed rotas were fairly allocated with a skill mix to meet the needs of the people living at Selly Park.

People and their loved ones told us they considered staff to be well trained and knowledgeable.

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.

Cleaning schedules were in place, and we observed the environment to be clean and fresh smelling. Staff confirmed they had access to plentiful supplies of personal protective equipment (PPE).

A member of staff had been appointed as infection control champion and took their role and responsibility seriously. They told us, “I ensure staff are doing it in the right manner and make sure they are wearing gloves etc.”

People told us they had no concerns regarding the cleanliness of the building. Representatives from the local authority infection prevention and control (IPC) team reported positively on the registered manager’s commitment to infection prevention control adding. One of the team told us, “[Registered manager’s name] is very engaged with IPC and open to suggestions and recommendations. They actively encourage staff to attend IPC training events and participate in IPC campaigns.” They also confirmed the registered manager promptly informed the appropriate authorities of any outbreak situations.

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.

People were supported to receive their medicines as prescribed, by staff who had received appropriate training and had their competencies assessed. Medication audits were in place to identify and act on any errors that occurred. Where people returned from hospital and their medication had changed, this was immediately shared with staff at handover prior to new medication administration charts being put in place.

An electronic medication recording system had been implemented, ensuring that any changes to medicines were updated promptly. Medication records included details of people’s allergies and their individual preferences for how medicines were administered. For example, 1 person preferred to take their medication with a glass of blackcurrant squash. Records also showed that people’s capacity to consent to receiving their medicines was documented within their medication care plans.

A member of staff told us, “I will always ask people before I administer medication, even if they do not have the capacity to consent.” They explained that 1 person experienced fluctuating capacity and was able to provide consent on some days but not on others. This demonstrated staff’s understanding of the importance of assessing capacity at the time of administration, rather than making assumptions, and of seeking consent wherever possible.