Catchpole 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 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 provider was in breach of legal requirements in relation to safe care and treatment and medicines management.
 

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Regular reviews were in place to monitor people's needs, such as those at risk of pressure care, falls and weight loss. Staff knew how to report accidents and incidents. The provider analysed incidents and accidents. This was used to identify any themes and trends and implement any learning to minimise risk. Following a recent safeguarding investigation the registered manager had started a system to embed a more robust process of analysing falls and with the support of a local authority further training was planned for staff.

Senior staff carried out pre-admission assessments prior to people moving in. This was to check Catchpole Court was able to provide the care and treatment which met people’s needs.
Staff shared information with other health professionals when appropriate to support people’s needs and provide continuity in their care.
People and their relatives said the service supported them to access GP services. Staff worked with external health and social care professionals when required to meet people’s health needs. For example, staff referred people for specialist advice and support such as dieticians and falls prevention teams.
 

Deprivation of Liberty Safeguarding (DoLS) authorisations were in place where people resided on units with locked doors. However, mental capacity and best interest assessments had not been carried out and evidenced in care plans for all people including those with bed rails in situ and those being administered medication covertly (hidden in food and drink). This meant restrictions on people’s liberty had not been fully considered as required by law.
Staff were trained to recognise abuse and understand their responsibilities to keep people safe from the risk of harm. Staff told us they felt comfortable to report concerns to the management team.
All staff we spoke with were aware of their responsibility to safeguard people and could describe the procedures in place in the event of a safeguarding concern. The registered manager was aware of the local authority thresholds for reporting safeguarding concerns and how to report to these as required for investigation.
 

Whilst we found no harm to people, improvements were required to ensure all care and risk management records contained enough information, to provide staff with the guidance needed to keep people safe from the risk of harm. People’s care plans did not all fully identify risks associated with their care and support needs.
People had equipment in place to help keep them safe from the risk of falls and pressure wounds, such as hoists, sensor and crash mats, pressure relieving cushions and air flow mattresses. However, care plans did not always contain enough detail to guide staff in the safe use of mobilising equipment including guidance as to the safe use of hoist slings. For example, a description of what colour sling loop to use to prevent the risk of falls from hoists. We observed staff incorrectly using hoist slings.
The electronic care plan system had been in place for 7 months. The registered manager told us the system was a work in progress. Staff told us the system was difficult to navigate and find the information needed. For example, there was no specific care plan meeting the needs of people with a catheter in situ and those diagnosed with diabetes. Instead, information was found in different areas of the care plan and not easy to locate. This was further complicated where staff recorded information in either the electronic care plan system and or in the medicines management system.

Care plans did not always contain enough information about how often people were to be repositioned to prevent pressure wounds, monitoring of bowel movements for people at risk, diabetes and catheter care.
Detailed guidance had not always been provided about how to care for people’s catheter. Care record documentation was inconsistent in relation to what signs staff should be aware of in detecting urine infections or if the catheter was blocked what action they should take in response.
Where care plans stated weekly catheter bag changes were needed daily notes did not evidence this had always taken place as required. There was a lack of systems in place to monitor and check how regularly catheter bags were changed. This meant people were at risk of acquiring infections.

We noted one person’s care plan stated they expressed suicidal thoughts. However, there was no risk management guidance for staff in how to respond and protect this person from the risk of harm.

Improvements were needed to the environment to enhance the experience of people living with dementia and enable them to orientate around the building. All walls along corridors had been painted in the same colour with a lack of signage to enable people to locate important rooms such as toilets, bathrooms and dining room. All doors along corridors had been painted in the same dark colour. There was no differentiation of colour to support people to access their room or bathrooms. We observed this impacted on the wellbeing of people living with dementia who we observed struggled to locate their rooms and orientate around the service.
We observed people sat in their rooms with their doors open looking out into the corridor where sensor lights would turn off making it dark for them to see out. We observed one person expressing distressed behaviours when the lights went out. We asked the management team to review the use of these lights and assess their potential impact on people.

We found insufficient numbers of dining room tables and chairs to enable everyone to eat at a table if they wished to do so. We observed people sat in lounge chairs trying to eat their meals from low coffee tables looking uncomfortable.
The provider’s management audits did not include an assessment of the environmental needs of people living with dementia or identify the shortfalls we found. In response to our feedback the management team told us they would consult with the provider’s dementia specialist team to obtain advice and support and review the environment, to ensure this met people’s needs.
 

The oversight of staff training needed improvement to ensure staff received the training relevant to their roles and robust records were maintained. For example, the staff training matrix showed that not all staff had been allocated the necessary training relevant to their roles and showed incorrect figures of compliance. This meant we could not be assured people were cared for by staff who had received all necessary training such as meeting the needs of people living with dementia, end of life care, fluid and nutrition to keep them safe and meet their needs.

The provider had a system in place to determine the number of staff needed to meet the dependency needs of people. Further work was needed in relation to the delegation of tasks to staff. Care staff were observed to be very busy and often task orientated. Where staff were required to be present in Gainsborough lounge to monitor people at risk at all times, we observed occasions when there was no staff present.

We received mixed views from people, their relatives and staff regarding the numbers and availability of staff at all times we observed. Some people told us they had to wait for support. One person said, “There are busy times of day when you have to wait a bit longer.” Another said, “Staff are always available when I need them. They are all very kind, all of them.”
A staff member said, “I enjoy working here. There are times when we are a bit pushed for staff.” Another said, “There are days when staff call in sick and we have to work with less staff. This can be hard. It is mostly weekends when they [management] try to get other staff to cover but it’s not always possible if it is last minute. We don’t have agency staff anymore.”
We observed people had access to call bells to alert staff when needed.
The registered manager told us vacant shifts were covered from within the staff team and the use of agency staff was rare.

Staff were recruited safely and told us they received induction training and regular supervisions. Pre employment checks were in place, such as previous employment references and police records checks. Clinical staff had regular checks to ensure they were fit to practice.
 

The provider assessed and managed the risk of infection.
There were systems to help prevent and control infections. Staff were trained to understand how to apply these. There were procedures to ensure the building and equipment were regularly cleaned, for audits of cleanliness and for staff to follow good hand hygiene.

Staff were provided with personal protective equipment (PPE) such as gloves and aprons.

People using the service and their relatives told us the premises including their bedrooms, were kept clean. Comments included, “It’s very clean here.” And ‘’Staff keep the place clean; I have no worries about that.’’

We observed the service was clean and odour free throughout and staff had access to personal protective equipment. We observed good levels of cleanliness and staff following appropriate procedures to minimise the spread of infection.

There was an infection prevention and control (IPC) policy and process in place. Notices about safe IPC practices were displayed throughout the service, such as hand washing procedures.

The registered manager reported monthly on infections within the service. This information was shared with the senior management team.
 

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Medicines administration was being recorded on an electronic system. We observed that people were not always having their regular medicines administered safely. Staff told us they didn’t always have enough resources to administer medicines in a timely manner. We observed the morning medicine administration round taking over three and a half hours to complete.
Equipment used to administer medicines was not always clean, such as the tablet crusher.
One person, who required dispersible medicines according to their care plan, was being administered a tablet, and an analgesic medicine which had been added to a thickened liquid but was not fully administered but was recorded as such.
The site of application of medicine patches used for pain relief was not always recorded and there was no daily check to ensure they remained in place. Some medicines that are recommended as best practice to be administered separately were being given at the same time as other medicines. One resident was prescribed a monthly medicine that could not be administered if their blood pressure was above a certain reading. Staff were not recording their blood pressure regularly, the last reading recorded was 10 days prior to our visit to the service. There was no care plan in place to guide staff to know whether it was safe for this medicine to be administered or not.
There were no easily accessible diabetic care plans to provide staff with the guidance they needed to keep people safe.
One person exhibiting distressed behaviours had been prescribed an antipsychotic medicine. There was no care plan guidance in place which would identify triggers and guidance for staff as to when this as and when needed medicine should be administered.
One person admitted to the service six days prior to our visit and refusing medicines had no medication care plan in place. Another person who was having their medicines administered covertly (disguised in food or drink) if necessary, had no best interest decision recorded. For medicines that could be given as and when required, there was not always a protocol in place to assist staff with guidance to know when to administer. For example, one person had an opioid prescribed but no guidance as to whether this medicine was for pain or breathlessness.
Homely remedies, such as paracetamol, if administered, were not being recorded on people’s electronic medicines administration record. Medicines were not always added to the electronic system accurately; a three-day antibiotic course had been added as indefinitely when they were prescribed for a specific length of time. Controlled drugs were stored and recorded appropriately.
Audits conducted by the management team had not identified the shortfalls we found during our assessment of the service.
In response to our feedback the provider told us they had taken action to rectify some of the concerns we identified.