Coralyn 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 Requires Improvement. At this assessment the rating has remained 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 continued to be in breach of legal regulation in relation to people’s safe care and treatment.

This service scored 47 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate safety events. The provider did not have a learning log in place and therefore lessons were not learnt, and good practices were not embedded.

The provider did work well with healthcare partners to establish and maintain systems of care. However, they did not always manage or monitor people’s safety. They did not always make sure there was continuity of care. For example, one person’s hospital passport did not contain information regarding their continence needs. The sharing of this type of information helps ensure the person receives continuity of care in a person-centred way. One health professional told us, “The staff are always considerate towards their residents in helping them settle, keeping us company and are always interested in my findings and listen to any additional advice I may have.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The provider told us they had not had any safeguarding concerns to report. Staff told us they had received safeguarding training and knew where the safeguarding policy was.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe and supportive. People were not empowered and supported to take risks. Care plans were not tailored to people’s individual needs and individual risks were not always considered to ensure people lived safely.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care. We found several environmental concerns. For example, the garden contained numerous trip hazards such as metal sticking out of the ground and uneven ground, a barbeque was stored in a communal area along with stepladders that was accessible to people. The environment had not been appropriately risk assessed, and risks had not been mitigated to ensure people’s safety.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. Pre-employment checks were completed appropriately, staff had received an induction and completed e-learning for training. One staff member said, “I feel supported by the providers.” Whilst staff told us they felt supported and the provider was approachable, staff were working long hours followed by ‘sleep in’ shifts. Staff were unable to clearly tell us when their ‘sleep in’ hours started. During the ‘sleep in’ shifts, staff were expected to wake twice during the night to support a person with personal care needs.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading. While the environment was clean, some areas of the home needed addressing. For example, we found a wheelchair being stored outside the front of the service which had visible rust. The provider did not have maintenance or cleaning records in place for people’s equipment, therefore putting people at risk of harm and infection.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff had received training and regular competency assessments. People received their medicines on time, as prescribed and they were stored and administered following best practice guidance.