The Coach House SBDP1 Limited

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 remains the same. This meant people were not safe and were at risk of avoidable harm.

The service was 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 always have a proactive and positive culture of safety. Incident records lacked essential detail, limiting understanding of risks. For example, fall reports did not describe what the person was doing at the time or whether injuries occurred, preventing effective learning and mitigation. Lessons learned were not always recorded, and when they were, they lacked depth and did not show meaningful analysis. Reviews of falls were not sufficiently detailed. Although locations, such as communal areas, were noted, there was no further examination of staffing levels or deployment at the time. The analysis failed to fully consider the contributing factors to the majority of falls.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. For example, the Provider’s accident and fall policy did not stipulate when to refer people to the falls team or safeguarding for specialist input. We were also concerned a referral to the Speech and Language Team had not been made in a timely manner. Whilst there were some shortfalls in this area, we saw from people’s care records other referrals were made.

People’s family members told us the staff worked well with other agencies involved in their relative’s care. We also received positive feedback about the support people’s relatives received when moving into the service and when they returned from a stay in hospital. One family member said, “[Relative] was [in hospital] for 10 days, discharge back to the home went well.”

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. The Provider had failed to always inform the Local Authority of safeguarding incidents. A review of the safeguarding log showed some incidents had been referred, but not all. Lessons learned from safeguarding incidents were not detailed, nor did they adequately show how the risk of future incidents could be minimised.

Staff received training in safeguarding and staff we spoke with, and a review of training records confirmed this. Most staff we spoke with had a good understanding of their responsibilities in relation to safeguarding and what signs they would look for if they suspected someone was being abused. However, some staff did not have a good understanding of the different types of abuse people could experience or what agencies to report concerns to.

The provider did not work well with people to understand and manage risks. Care records showed significant gaps, with important health and wellbeing risks not properly assessed or planned for. One person lacked risk assessments for two known risks, and another had no choking risk assessment despite concerns about coughing and poor positioning during meals. Fluid intake records showed people were not receiving enough to drink, increasing the risk of dehydration and pressure ulcers; two individuals went 16 and 19 hours without fluids. Staff acknowledged difficulties offering drinks consistently. Risks to skin integrity were also poorly managed. One person, who required repositioning every two hours, had no evidence this occurred, and daily notes showed they were often left in wet clothing.

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’s Personal Emergency Evacuation Plans (PEEPs) contained conflicting information. Some PEEPs were also out of date and required a review.

During the inspection, we noticed some windows did not have restrictors fitted and opened widely. We spoke with the provider about this, and we have been given assurances immediate action was taken.

Risk assessments were in place for all areas of the service, and we saw these were regularly reviewed. Regular checks of firefighting equipment, electrical and water safety were also undertaken.

The provider did not always make sure there were enough qualified, skilled and experienced staff. Relatives gave mixed feedback: some felt staffing levels were low or that more staff were needed to support people who stayed in their rooms, while others said there were “plenty” of staff. Some staff also reported shortages. Communication was not always effective, as language barriers sometimes limited clarity. Not all staff had completed mandatory training, including key areas such as falls management and tissue viability, though supervision and annual appraisals were in place and documented. Recruitment processes were safe, with appropriate pre‑employment and Disclosure and Barring Service checks completed. Some staff files lacked photographs, but the provider addressed this before the end of the site visit.

The provider did not always assess or manage the risk of infection. During the inspection we noted some areas where there were malodours. There was limescale on some of the fixtures in bathrooms, and this can harbour bacteria. Some items of furniture and equipment was torn and frayed, and some laundry bins were cracked, all increasing the potential for bacteria to thrive.

We saw the general cleanliness of the service was acceptable with regular cleaning schedules in place. Kitchens and laundry areas were cleaned and were organised. We observed staff wearing personal protective equipment such as gloves and aprons where necessary.

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. Medicines were stored securely, kept at correct temperatures, and administered as prescribed, with staff assessed as competent. However, covert medicines were sometimes given in foods different from those in written guidance. Updates to guidance were not always made promptly after prescriber changes, creating risk of confusion. Important information was missing, including person‑centred guidance for occasional use at the discretion of staff, body maps for topical medicines, and clear blood glucose thresholds for insulin‑treated individuals. Records did not show appropriate rotation of medicated patch sites. Stock checks occurred, but audits were not thorough enough to identify these issues.