Cheverells 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.

At our last assessment we rated this key question good. At this assessment the rating has changed to 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 managing medicines, staffing and infection, prevention and control.

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 based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The deputy manager reviewed all accidents and incidents within the service and took appropriate action to address these on an individual basis, however, opportunities to identify themes, trends and lessons learnt were not always completed. For example, staff meetings were irregular meaning staff had limited opportunity to learn and continually identify and embed good practice. One staff member told us, “I am not sure, there’s possibly been 1 or 2 staff meetings this year.”

We observed a staff member not being provided up to date information relating to people’s end of life status before coming on shift.

Staff told us they reported any accidents and incidents when things had gone wrong. One staff member told us any lessons learned would be shared at shift handover.

However, relatives told us they were kept informed when concerns arose. One relative told us “The home will let me know if they have any concerns. The home will ring me if the physio is coming, keeping me in the loop. If [name] has had a fall, they will always let me know.”

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. On inspection, the deputy manager told us they did not have anybody living at the home who required a Speech and Language Therapy (SALT) assessment in place. However, a SALT assessment for a person was observed in the kitchen. We asked the deputy manager to clarify this, to which we were told this was an old SALT assessment and the person no longer required it. This provided unclear guidance on how best to meet a person’s care and support needs. We asked for evidence of this but have not received supporting documents.

Relatives told us communication between the care home staff and health providers was positive. One relative told us, "We've had meetings here with me and my siblings to discuss any changes to our family members care and they keep us updated if anything happens with them."

Staff had a good knowledge of which health and social care professionals supported which people. Staff were able to explain when these professionals visited, and what type of support they offered. One staff member told us, “We have time to sit with external professionals, to go through the main points, as to who needs support or changes. This has really improved our handovers.”

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve this. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. People and their relatives we spoke with all told us they or their family members felt safe within the home and with staff. One person said, "I feel safe in my bedroom and when I get down in the dumps, the staff cheer me up." A relative told us, "I've ease of mind about my family member being safe here. The staff are very safety conscious too."

We reviewed staff training records and found most staff had received training in how to safeguard people. However, we found some staffhad not completed safeguard training. The provider had not ensured all staff were suitably trained to identify safeguard concerns, which placed people at risk of abuse.

People and their relatives told us there were no unlawful restrictions imposed on them or their family members. They were free to complete their own routines and live their lives as they wished. Some people would be at risk if they did not have continuous supervision and control; where this was the case, we saw staff had applied the suitable Deprivation of Liberty Safeguards. These safeguards ensure people who cannot consent to their care arrangements in a care home or hospital are protected if those arrangements deprive them of their liberty.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People we spoke with or observed appeared to be satisfied with their equipment provision and safety devices. Walking frames were labelled or decorated to help people and staff identify each one. We observed staff hoisting people in the lounge into wheelchairs to move into the dining room. These manual handling procedures were carried out in a calm, efficient manner with friendly interactions between staff and people. People told us staff understood their needs well and offered support to keep them safe. One person said, “I get stuck in bed as I can’t turn over easily, so I have some help getting up on my feet. I’ve got a frame and can walk slowly to the toilet with a carer, as it helps me to use my legs.”

People and their relatives told us they were able to communicate their or their family members’ needs, to ensure they received the right type of support. One relative told us, “My family member can still stand and balance to be placed into their wheelchair. They have a sensor mat and their bed set very low as they will try to move around and had experienced previous falls.”

People’s needs were clearly documented in their care plans, which meant staff had clear guidance on a person’s mental, physical, and social needs. Staff knew how to support people to manage risk. For example, where people living with a risk of falls required the support of staff for mobilising or moving from a chair to a bed with the assistance of equipment.
We found personal emergency evacuation plans had been regularly reviewed, ensuring they fully considered the unique needs of people. Staff had clear processes in place for how to respond to an emergency and the evacuation processes to follow.

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.

On inspection, we identified gaps in the recording of weekly and monthly health and safety environmental checks. For example, the weekly health and safety audit and carbon dioxide weekly checks had not been completed for 2 weeks. Furthermore, we found records for the previous 4 months highlighting a particular faulty fire door which required maintenance but had not been fixed. This was raised with the deputy manager who took immediate action to address the concern.

Staff knew how to monitor the safety of the environment, and where to report any maintenance concerns. The maintenance team described a clear process for monitoring environmental safety concerns. The environment was kept safe, by regular checks and maintenance. We saw there had been regular checks to ensure the home was safe in the event of a fire (for example, by checking the alarm systems.) Systems were in place to ensure the water quality was maintained to reduce the risk of water-borne bacteria (like Legionella.) The gas heating system was regularly serviced to prevent harm to people.
Staff knew how to respond in the event of an emergency evacuation. For example, if a fire alarm sounded, staff could explain how people would be supported to move into a safe space.

The provider did not always make sure there were enough qualified, skilled and experienced

staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

We looked at 8 staff files and found gaps in the information in all files. For example, 4 staff member’s employment history was incomplete, and references on files did not always relate to any previous employment listed or referee’s named on their application form.While we found improvements were needed in the safe recruitment of staff, we found people had not been harmed as a result of the gaps we identified. We reviewed 2 staff induction records and found gaps in both. For example, 1 staff member had no record of their induction being completed or their competencies assessed prior to working unsupervised. Staff assured us they had received an induction, with 1 staff member telling us, “I always buddied up with an experienced staff member for the first month, I was well looked after and have completed my training,” improvement was needed to ensure staff inductions were fully documented. However, the provider did not have an effective system in place to manage staff training and development.Training records showed there were gaps in staff training linked to people’s needs, for example 3 staff providing personal care had been identified as not completing training in Dementia care and safeguarding awareness. We received mixed feedback regarding staffing levels. One person told us, “We are always short of staff here and you press your bell, and it may be 5 minutes or 15 minutes before a staff member arrives”. One relative told us, “I know how difficult it is to keep staff. I haven’t had any concerns though”.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading.

We observed a bucket with soiled laundry on a sink in the laundry room on both days of our site visit. This breached Cheverells own infection, prevention and control policy. We discussed this with the deputy manager who told us, “We will get that sorted out and arrange for agency staff to pick up shifts rather than take domestic staff off the floor”. The registered manager had delegated checks on infection prevention to care staff. During our inspection, we identified some areas where the provider’s policy or safe practices were not always followed. For example, we found gaps in recordings of deep cleaning of people’s bedrooms and communal areas. We also found gaps in the daily cleaning of the kitchen. One staff member told us, “Not enough housekeepers on weekends, so bathrooms don’t get cleaned and bins are not emptied”. The registered manager told us they would increase their oversight of checks made to ensure a high level of infection prevention and control was consistently maintained. Staff had access to personal protective equipment (PPE), which they used when supporting people with personal care. Training records showed there were gaps in staff training linked to people’s needs, for example under a third of staff providing personal care had completed infection control training. One relative told us, “There was an issue which was remedied. [Name] would wear the same clothes all week, and I said, ‘Can you send someone in to take them away in the evening’. They [staff] go in now and take [name] dirty clothes away. That’s been managed, and now [name] has clean clothes every day.”

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We observed medicines were not always recorded by staff in line with the service medicine policy. For example, on inspection, we found gaps in signing of medicines being administered, and the provider could not be assured the person’s medicine had been administered as prescribed. We also found medicines had been signed for as administered, but this was inaccurate. We observed the medicine trolley being left unlocked and unattended by a staff member. This was unsafe practice and did not meet legal requirements as outlined by National Institute of Health and Care Excellence Managing Medicines in Care Homes (NICE SC1). This breached the service policy on the safe administration, handling and disposal of medicines. We asked the deputy manager to take immediate action to ensure the safety of people and medicines, which they did. People had not come to harm because of this error.

Staff ensured people received medicine reviews by their GP. One person’s relative told us they had recently had a medicine review by the GP and was now, “Much better and more alert.”