Priesty Fields 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 inadequate. 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 provider was previously in breach of the legal regulations in relation to people’s safe care and treatment including the way people’s medicines were managed and safeguarding people from abuse and harm. Whilst some improvements were in progress, the provider remained in breach of these regulations.

The provider was previously in breach of the legal regulations in relation to the premises, staffing and fit and proper persons employed. Improvements were found at this assessment and the provider was no longer in breach of these regulations.

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.

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.

Since our previous assessment, managers had focused on identifying safety issues and where necessary undertaking investigations. Staff were being supported to report accident and incidents in line with procedures. They were taking actions to learn any lessons where required. Where themes had been identified work was in progress to improve staff practice and create a positive culture. This work was ongoing and needed to be embedded and sustained. Staff told us they felt improvements were in progress and management were now following up on issues, sharing lessons learnt, for example, from accidents and incidents.

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.

We received mixed feedback from partners about the continuity of the care provided. Some visiting health professionals were positive about staff and told us they had noted some recent improvements. However, other feedback highlighted concerns about aspects of the care provided to people, especially with complex needs. Managers were focusing on staff training and performance.

Staff referred to healthcare partners for specialist assessments where required. Managers were focusing on updating people’s care records to ensure these were accurate and up to date. However, we saw an example where staff had not completed a care plan in a timely way for a new person. The manager took immediate action to address this.

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. However, they were focusing on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

Overall, people told us they felt safe living at Priesty Fields. Since our last assessment, managers were ensuring staff identified and reported safeguarding concerns appropriately. They had used meetings and daily observations to help identify issues, improve communication and staff practice. More recently, records demonstrated staff had identified and reported various issues. Staff told us they had received training and felt able to raise any concerns.

However, the provider needed to ensure systems were further strengthened and embedded so staff always reported safeguarding concerns correctly. They needed to ensure their oversight was robust and systems put in place were sustained. Whilst managers had made several safeguarding referrals, we found 3 cases where staff had either not reported a concern to their manager or when reported, it had not been escalated through local procedures to the local authority. Two of these examples were prior to the current management team being in post. Whilst no harm had occurred, the manager subsequently ensured these incidents were reported appropriately and CQC were notified.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Since our last assessment, the provider had been focused on more effective risk assessments being undertaken. Staff were reviewing and re-writing people’s care records. This work remained in-progress. Whilst some people had appropriate risk assessments and care plans in place, for others, these were not always up to date or provided consistent information to guide staff. For example, staff had not undertaken a risk assessment in relation to the way a person used their wheelchair, which placed then at potential risk of falls. Staff had not always undertaken risk assessments when people undertook certain activities, such as taking part in activities in the community. In response, the provider took actions to address these issues.

Managers were acting to improve records relating to people's nutritional needs and risks, having reviewed systems to ensure records were accurate and staff understood people’s needs. However, this needed to be further embedded and sustained. For example, one persons’ record relating to the consistency of their drinks, was inconsistent and not always in line with what staff were providing. Whilst staff had made adjustments in response to the person’s needs, they agreed to seek further specialist advice and to ensure records accurately reflected the person’s current needs.

Managers had identified the need to undertake reviews with people and to involve their family members where appropriate, these remained in progress. A relative said, “Recently they have set up a monthly review with the nurse so we can catch up.”

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.

Following our last assessment, the provider had taken action to address potential risks in the environment. The third floor was currently out of use until further adaptions were made. Building work was in progress to ensure balconies were safe for vulnerable people. The provider ensured appropriate health and safety checks, and maintenance of the building was carried out.

However, staff had not always followed procedures in place to reduce identified risks. For example, thickening powder which should be kept locked away for safety, had been left out in a communal area. Where cupboards contained items which could cause harm to people, staff had occasionally left them unlocked. In response to our feedback managers took immediate action to improve this.

The provider had arranged for an external fire risk assessment to be undertaken. Managers had focused on ensuring staff undertook fire training and drills, as well as improving processes to ensure staff had access to current evacuation plans for people. However, the provider had not ensured all the actions required following an audit undertaken by the local Fire and Rescue Service in March 2025, had been carried out effectively. This related to effective evacuations and guidance to staff. We shared this information with the local fire safety officer. The provider has told us they have now taken action to address this.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They were taking action to ensure staff received effective support, supervision and development. They were making changes to ensure they worked together well to provide safe care that met people’s individual needs.

Since our last assessment, the provider had recruited new staff and used less agency staff. A relative commented, “Now there seems to be continuity of carers helping [relative] and I hope they will keep that going.” However, agency staff were still required at times, and feedback indicated some of these staff did not always understand people needs as well as regular staff. A person said, “The main staff are friendly and helpful but the agency don’t know as much.” Managers told us they were aiming to ensure regular agency staff were used to help with consistency.

Overall, during our visits staff were responsive to people’s needs. Staff feedback suggested they felt there were sufficient staff. However, some people expressed frustration about the time it took for call bells to be answered. People commented, “Don’t seem to be many on at night and I think they are a bit short staffed” and “I do use the bell, but I have to wait because there are only 2 on [care staff allocated to a particular area] and they get busy.” The provider used a dependency tool to help assess staffing levels required. However, we noticed some inconsistencies in the information within the tool which did no match aspects of people’s care plans. The provider was undertaking a further assessment of home and the organisation of the units, in consultation with people, to further support staffing deployment and responsiveness.

Managers were focused on training, for example, all staff were being re-trained in moving and positioning people. Further training was in progress including supporting clinical staff with leadership skills. A staff member said, “They've increased the training; put out more courses and encouraged us to attend, eLearning has to be 100%.” The provider had arranged workshops to support staff with the electronic recording systems. Feedback indicated potential variations in the standard of guidance provided to new staff about the electronic system, which was dependent on the skill of the staff providing the induction. The provider confirmed they would further consider formalising this training requirement, to ensure staff received consistent training in this area.

Staff supervision and appraisal meetings were in progress. Schedules to ensure these continued needed to be embedded and sustained.

The provider had systems in place to ensure staff were recruited safely. However, these needed to be strengthened further, as we saw some gaps in records related in staff employment histories. This included records in relation to agency staff. The provider had undertaken an audit of staff recruitment records, actions were being taken to ensure any gaps were addressed, some of these related to recruitment undertaken by the previous provider.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The environment was clean and odour free. Managers had supported staff in implement new cleaning schedules. PPE was available for staff. Where staff had specific requirements relating to PPE, this had now been provided. The local infection prevention and control team were supporting managers to provide staff with further training.

The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

They had not ensured medicines were always stored safely, including some controlled drugs. The provider took immediate action to ensure all storage areas were made secure.

Staff recorded the administration of medicines on medicine administration records (MAR). However, they had not always followed best practice guidance, in relation to handwritten MARs. Staff carried out regular medicine audits, however, they had failed to identify all the concerns related to medicines management we found during our assessment.

Records relating to people’s medicines were not sufficiently robust. When people had been prescribed medicines to be given on a ‘when required’ basis, not everyone had a protocol in place to guide staff in a clear and consistent way. Where people required time critical medicines, staff had not recorded on the MAR, the exact time to give the medicine or the time it had been administered, this could increase the risk of errors. Staff had not always followed the provider’s medicines policy in other aspects of recording.

Care plans for people with complex medical conditions such as diabetes and epilepsy did not always support safe care. We saw 2 examples where Information contained within people’s care plans did not match the information on their MAR. Details to allow staff to know how often a person had seizures and the steps to follow when administering rescue medicine were not included in the care plans.

We could not be assured where staff administered medicines covertly (when medicines are administered in a disguised format) to people, this was being done safely. In these cases, there were no records to show if decisions had been made in people’s best interests in line with The Mental Capacity Act 2005. Records did not provide any pharmacist advice about how to give the medicines safely. MARs did not contain directions to say the medicines could be given covertly if needed. The provider took some immediate actions during the assessment to address these issues.

We checked the quantities and stocks of medicines and found stock balances to be correct.