Surrey Oaks Nursing 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. This key question has been rated Good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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 fostered a culture where staff discussed and learnt from things that went wrong. Staff reported and recorded accidents, incidents and concerns. These were investigated in accordance with a clear incident management policy and procedure and appropriate action was taken to keep people safe and improve the service. Managers discussed lessons learnt in staff meetings to enable staff to share best practice and learn from each other.

The provider supported people to have safe transitions and pathways. The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. People’s care records included information from other professionals to ensure care was joined up.

The registered manager confirmed they worked with other partners to ensure there was continuity in the management of people’s care. There were established systems in place for admission to or discharge from hospital.

The provider had clear and effective systems and processes in place to make sure people were safe from the risk of abuse. People told us they felt safe at the service and with care workers. One person told us “I don't feel at risk here at all. The Home is pretty well set up. I don't really have a problem.”

Staff received safeguarding training on an annual basis and had a good understanding of safeguarding procedures. One care worker told us “100 per cent people are safe. We’ve had training about what to do if we’re concerned about people and I’m confident that if I reported an issue, it would be dealt with.”

The provider shared concerns quickly and appropriately. There were clear safeguarding and whistle blowing procedures in place and the manager confirmed they were aware of when to report concerns.

The provider worked with people to understand and manage risks to their health and safety. There were clear and personalised risk assessments in place covering different areas of people’s health and safety. These were reviewed on a monthly basis and were adapted in accordance with people’s changing needs. This included areas such as people’s mobility and their risk of falling or their risk of choking. Where specific and new risks were identified, we saw prompt action was taken to manage these, for example, through contacting multi- disciplinary professions for extra support.

We identified one example of inconsistencies in a person’s repositioning records as well as inconsistencies in the length of time taken to dress another person’s wounds, however, the provider was monitoring people’s skin on a weekly basis thereby minimising the risk of deterioration. We also noted that since the implementation of the weekly check of people’s skin, all people’s wounds had healed.

Staff had a good understanding about the risks to people’s care and gave us examples of individual people they provided care to. All staff have received specific pressure sore awareness training.

The provider detected and controlled potential risks to people’s environment. They made sure equipment, facilities and technology supported the delivery of safe care. There were clear environmental risk assessments conducted that included areas of risk both inside and outside the premises. Where issues were identified, these were followed up and actions were taken to remedy these.

The home was not always dementia- friendly, it was not personalised and did not contain any items for people to orient themselves. We spoke with the manager who confirmed there were plans in place to redecorate the premises.

People and their relatives told us the environment was adequate for their needs. One relative told us “It is fine. It is fit for purpose.”

People’s equipment, for example, hoists were regularly reviewed to ensure they were safe for use. We observed the environment was safe during our assessment and people could move around freely and safely.

The provider made sure there were enough qualified, skilled and experienced staff in place to support people. The provider carried out pre- employment checks on staff to ensure they were safe to work with people and provided a comprehensive induction, which included training and a period of shadowing of other staff.

The provider ensured staff received ongoing support, supervision and development to ensure they remained able to provide safe care that met people’s individual needs. The provider carried out quarterly supervisions and annual appraisals and there was an ongoing system of training in place. Staff told us they found the support useful and were able to request further support if needed.

Staff told us they felt there were enough of them on shift to support people. One care worker told us “There are enough staff all the time. When there’s a hospital appointment or something, they make sure there are enough staff to do this.”

We observed there appeared to be enough staff working during our assessment. We observed that call bells were responded to quickly. We reviewed call bell records after our assessment and records indicated that people were seen promptly.

The provider assessed and managed the risk of infection. There was a clear infection control policy and procedure in place.

Staff had received infection control training and had a good understanding about their responsibilities. They confirmed they were given the equipment they needed to maintain good infection control.

We observed staff wearing PPE where necessary and people had individual slings for their use where needed. The environment appeared clean and there were clear cleaning protocols in place to ensure the premises were hygienic.

The provider ensured medicines were given safely and met people’s needs, capacities and preferences. People confirmed they got their medicines on time. One person told us “I have lots of medicines and they give them to me whenever I need them.”

There were clear medicines care plans in place and these included details of what medicines people were required to take, when and why. Care staff recorded when people were administered their medicines on Medicine Administration Record Charts (MARs) and these were audited on a monthly basis. PRN protocols were in place and we saw these administered safely. Medicines were stored safely in accordance with requirements.

Staff involved people in planning, including when changes were required to their care. We saw medicines risk assessments were completed to determine what level of support people required with their medicines and these were reviewed if people’s needs changed.

Staff received annual training in medicines administration and had their competencies checked. There was a medicines administration policy and procedure in place.