Stratton 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.

This is the first assessment for this newly registered service. This key question has been rated Good.

Good: This meant people were safe and protected from avoidable harm.

This service scored 62 (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.

The provider had a system in place to review accidents and incidents. The registered manager told us they carried out a root cause analysis to examine incidents and identify themes and trends. For example, the provider had carried out an analysis of falls. This identified a pattern of falls happening in the late afternoon near the dining room and was a result of people forgetting their mobility aids. In response to this, the registered manager held a meeting with staff and discussed the importance of supporting people to bring their mobility aids to the dining room. Additional safeguards were also implemented. Staff told us information about learning from incidents was shared with them during handover and in staff meetings.

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.

The systems to support people did not consistently work to ensure people were supported safely. Where people’s health needs had changed, the systems did not always ensure staff communicated this appropriately and staff did not always have access to or followed updated guidelines from health professionals. This meant people did not always have their care needs met safely.

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.

People told us they felt safe at the service. One person told us, “It’s nice in my room and I keep it nice. I think they’d listen to anything you wanted. It’s a pleasant enough place to stay.” A relative told us, “This is a marvellous home.” Staff understood how to recognise signs of abuse and knew how to report any concerns. Incidents were referred to the safeguarding body for investigation. The registered manager told us they carried out root cause analysis when a safeguarding occurred to consider any learning and look for areas of improvement. Where people were deprived of their liberty, applications had been sent to the authorising body, and these were referenced in people’s care plans.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service 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.

We observed improvements had been made to the environment since the last inspection. We noted areas had been refreshed and the service was clean and free from dust in the communal areas and stairwells. The registered manager had implemented a new system for staff to report maintenance concerns using a QR code and this had a positive response from staff. The general manager told us, “I do spot checks, staff use the QR codes, and I check competencies. I do monthly competency checks for the maintenance team.” However, we found several environmental issues which had not been adequately addressed which posed a risk to people with reduced capacity. For example, in one person’s bedroom who had dementia, a wall tile in the bathroom had been removed to be replaced, but no one had put a cover on the area, and it was open to the pipework which posed a risk to the person. We also found the curtain in another person’s room had been pulled off the rail but had not been repaired. Some people had out of date food in their personal fridges, their windowsills were dusty, and their toilets had not been cleaned. We did not find anyone had come to harm, and our observations were fed back to the registered manager and general manager who took immediate action.

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.

Staffing levels matched the staff duty rota on the day of our site visit. Staff were visibly present throughout this inspection and were quick to respond to people’s questions and requests for support. Staff were well-trained to meet people’s individual needs, in line with their choices and preferences and encouraged to continually improve in their role. Staff received a mixture of e-learning and in-person practical and theoretical training, which was routinely refreshed as frequently as staff required it including competency-based assessments. Newly employed staff were subject to a probationary review and records showed staff received an induction to their role and ongoing training and support to ensure they could meet the needs of people living at the service. Staff had ongoing opportunities to reflect on their working practices and to identify any further training, learning or support they might need. Staff had regular individual and group meetings with their fellow peers and line managers.The provider continued to operate safe recruitment practices and only fit and suitable staff were employed to work at the service. Staff files contained evidence of robust recruitment checks including application forms where gaps in employment were explored, professional and personal references, right to work and identity checks were in place. The provider maintained a recruitment tracker to monitor staff recruitment and completed Disclosure and Barring Service (DBS) checks. A DBS check helps employers make safer recruitment decisions by processing requests for criminal record checks of individuals applying for certain jobs, particularly those involving children or vulnerable adults.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

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.

The provider’s medicines administration systems ensured medicines were managed safely. The provider’s systems ensured accurate recording of medicines stock. We checked medicines records and stock and found these matched. Where people had ‘as required’ medicines, guidance was in place to ensure this was administered in line with how it was prescribed. Medicines which were time sensitive were given in line with instructions, and one staff member had set an alarm to help ensure the person received their medicine on time. Staff were aware of the procedures for reporting concerns. We found some medicines which were no longer required were still being stored in medicine fridges and in people’s rooms, but staff acted quickly to remove these. People told us they received their medicines as prescribed. A person told us, “They come in the evening to help me with my eyedrops – this helps me settle for bed.” Relatives did not give any negative feedback. External professionals told us they had observed improvements with how medicines were managed at the service. One visiting professional told us, “Communication is excellent, it’s much better since change of management; the service is very stable now."