Snydale 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 this 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 and staffing.

This service scored 44 (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. Lessons were not always learnt to continually identify and embed good practice.

Although accidents and incidents were recorded and staff were aware of reporting procedures, oversight was insufficient.

Systems and processes for monitoring and analysing incidents were not sufficiently robust. This resulted in missed opportunities to identify trends, implement learning, and improve outcomes, leading to inconsistencies in practice and a failure to ensure continuous service improvement.

The provider did not work effectively with people or health system partners to establish and maintain safe systems of care. There were significant failures in the oversight and management of people’s safety, and the provider did not ensure continuity of care, including during transitions between services.

Although some pre-admission assessments had been completed prior to people moving into the service, these were often insufficiently detailed and failed to provide clear, person-centred guidance for staff on how to support individuals safely.

We found limited evidence robust pre-admission assessments had been consistently undertaken. There was a lack of understanding of people’s care and support needs, and care plans and risk assessments frequently relied on inaccurate or outdated information, including hospital discharge documentation. There was no clear evidence to demonstrate people were appropriately placed within the service or their needs could be safely met by staff. When questioned, staff were unable to explain why some individuals were residing at the service, indicating a lack of knowledge and oversight.

Although concerns we raised prompted immediate action from the manager, significant shortfalls remained at the time of inspection. Systems to review and update care plans in response to changing needs were not fully effective. As a result, staff were not consistently provided with the accurate and up-to-date information required to deliver safe and effective care.

The provider did not consistently work in partnership with people or healthcare professionals to understand what being safe meant to individuals or how this could be effectively achieved. There was insufficient focus on improving peoples lived experiences or upholding their right to live safely, free from bullying, harassment, abuse, discrimination, avoidable harm, or neglect. Concerns were not always shared in a timely or appropriate manner.

Systems in place to safeguard people were not sufficiently robust or effectively operated. We identified incidents that had not been recognised or managed as safeguarding concerns by the provider. Safeguarding alerts had not been raised with the local authority, and required notifications to the Care Quality Commission (CQC) had not been submitted. This demonstrated a failure in the provider’s governance systems to identify, assess and mitigate risks relating to the health, safety and welfare of people, and to ensure compliance with statutory responsibilities. These concerns were raised with the manager during the inspection, who took immediate action.

Safeguarding policies were in place and staff reported receiving appropriate training, with an understanding of their responsibilities and the ability to recognise the different types of abuse and escalate concerns.

We checked whether the service was working within the principles of the Mental Capacity Act, whether appropriate legal authorisations were in place when needed to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. All legal applications had been made in accordance with Deprivation of Liberty Safeguards (DoLS). This meant people’s rights were fully respected. The manager kept a record of DoLS applications and authorisations, and this was regularly reviewed to make sure authorisations were current.

The provider did not consistently work in partnership with people to understand and effectively manage risks. Care delivery did not always ensure people’s needs were met in a safe and supportive way, nor did it consistently enable individuals to achieve outcomes that mattered to them.

We identified a lack of robust oversight and management of risks across the service, particularly in relation to malnutrition and skin integrity. For example, the manager informed us of a person who had developed pressure damage; however, there was no documented evidence of this within the person’s care plan or risk assessments, nor any clear guidance outlining measures to mitigate the risk of further deterioration. This demonstrated a failure to assess, monitor and respond appropriately to known risks.

We recognised a person’s malnutrition screening tool had not been accurately or fully completed. As a result, significant weight loss had not been identified through internal monitoring, putting the person at risk of avoidable harm. This indicated ineffective systems for assessing and escalating risks relating to nutrition and hydration.

We also found that a person identified as being at high risk of falls had been provided with a privately sourced falls alarm device. There was no documented rationale for its use, no associated risk assessment, and no guidance within the care plan to support staff in its safe and appropriate use, including any contraindications. This placed the person at potential risk and demonstrated a lack of safe, coordinated care planning.

These concerns reflected a failure to ensure risks to people’s health, safety and welfare were effectively assessed.

The provider did not consistently identify and manage potential risks within the care environment. There were shortcomings in ensuring that equipment, facilities and technology effectively supported the delivery of safe care.

During both inspection visits, the service’s call bell system was observed to be sounding continuously. The manager advised this was due to a known fault and action had been taken to replace it. However, this potentially put people at risk, as it may have reduced staff responsiveness to people’s requests for assistance and impacted on their safety and wellbeing.

Although the environment was generally well maintained and some refurbishment work had been completed, other areas of the service were in a state of disrepair and required improvement. While routine environmental checks of systems and equipment were undertaken, a fire risk assessment had identified areas of concern for which evidence of action taken was not immediately available during the inspection. This information was only provided at a later stage in the inspection process, indicating gaps in oversight.

Fire safety systems were in place, and records confirmed regular servicing and fire drills. Staff demonstrated an understanding of fire safety procedures, and personal emergency evacuation plans were in place for individuals to support safe evacuation in the event of an emergency.

The provider failed to ensure there were sufficient numbers of suitably qualified, skilled, and experienced staff to meet people’s needs safely. Systems to support, supervise and develop staff were not consistently effective, and team working was not sufficiently coordinated to deliver safe, person-centred care.

Feedback from staff, relatives, and our observations during the inspection indicated staffing levels were inadequate. (On the first day of the inspection, we observed the manager undertaking care tasks and serving meals to support staff). We observed people attempting to alert staff and being left for extended periods without support, resulting in discomfort and unmet needs.
There was a high reliance on agency staff across all shifts. Permanent staff and relatives expressed concerns regarding agency staff’s competence, unfamiliarity with the environment, and limited understanding of people’s individual needs. This placed additional pressure on permanent staff, who were required to provide support and, which impacted further on the ability of staff to provide safe care.

Staff confirmed staffing levels were insufficient. Comments included, “There are only 2 staff per floor and it’s not right. At times there hasn’t been anywhere near enough staff, which puts pressure on us, and we feel we haven’t given adequate care.” This reflected a consistent and widespread concern regarding staffing capacity and its impact on care quality.
Although some staff supervision had been undertaken, this had not been effective in promoting a positive culture or supporting staff to perform their roles safely and confidently.

The provider had followed appropriate recruitment processes, including pre-employment checks such as references, employment history checks, and Disclosure and Barring Service (DBS) checks. Staff training was mainly up to date, with additional training booked in.

The provider did not consistently assess or manage the risk of infection, nor did they take effective action to prevent and control the spread of infection. Concerns were not always identified, escalated, or shared promptly with relevant agencies.

Parts of the environment were in disrepair, with worn surfaces that could not be effectively cleaned, increasing the risk of infection transmission. On the first day of inspection, we observed soiled equipment and unclean toilet facilities, which presented an infection control risk. Although some improvements in general cleanliness were noted on the second day, this highlighted inconsistencies.

The manager told us the provider had sourced a private supplier of medical-grade cleaning with plans to improve cleaning practices. However, at the time of the inspection, these improvements had not yet been fully implemented.

Staff were observed using personal protective equipment such as gloves and aprons, and reported they had received infection prevention and control training and understood the relevant protocols.

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.

. Staff supported people with their medicines in a kind and respectful way, and residents appeared comfortable during medicines administration.

Medicines administration records were completed appropriately, and staff demonstrated an understanding of the importance of reporting medicines incidents.

The provider completed medicines audits and recorded action plans when issues were identified. However, medicines management systems did not always ensure safe practice. Fridge temperature monitoring did not consistently provide assurance medicines were stored safely, and recording did not always reflect actual temperatures.

The service did not always manage homely remedies as per their policy, including the administration of expired paracetamol and gaps in GP signed agreements.

Medicines stock management did not consistently ensure availability, which resulted in some missed doses. Controlled drugs, which are medicines liable to misuse, records were not always completed accurately, and oversight arrangements did not consistently identify discrepancies.

Care plans and medicines documentation did not consistently reflect a person-centred approach or provide clear guidance for staff, particularly for medicines prescribed as a variable dose or as and when required. Time critical medicines were not always given within recommended time frames, and staff did not consistently escalate delays for clinical advice. On some occasions, staff administered medicines very early in the morning, raising concerns about how well administration times reflected people’s individual needs.

Risk assessments linked to medicines use and pain assessment for people unable to communicate, were not consistently in place. Documentation for covert administration, giving medicines hidden in food or drink, was not always up to date or clearly recorded.