Deneholme Care Centre

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

This service scored 69 (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 accidents and incidents we reviewed were recorded and reported correctly. Relatives told us staff listened to any concerns and acted quickly. One relative said, “[Registered manager] is very good at initiating communication. The staff learn from residents what they like and want to put things right if the smallest of things is wrong.”

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 experienced consistent and coordinated care, including when moving between services such as hospital settings. Relatives were involved in care planning and told us they felt informed and reassured during transitions. Staff maintained a visible presence and responded promptly to people's changing needs, helping to ensure timely care and support.

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. However, the provider had not always shared concerns quickly and appropriately with the local safeguarding team.

Staff received training and demonstrated an understanding of their responsibilities for identifying and escalating concerns. While we identified incidents that should have been reported to the local safeguarding authority but had not been notified, the provider had taken appropriate action to protect people and promote their wellbeing. This included making timely referrals to relevant healthcare professionals to ensure people received the support they needed. The registered manager said they would work with the safeguarding team to ensure processes were updated.

Information was generally shared appropriately to support safe care. People and their relatives consistently told us they felt safe using the service. One person said, “Of course I feel safe, I wouldn’t stay if I wasn’t safe.”

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’s care plans and risk assessments contained information about their care and support needs, as well as identified risks and the measures in place to manage them. People and their relatives confirmed they had been involved in developing and reviewing these documents. Staff were able to access care records and demonstrated a good understanding of people’s individual needs and associated risks, including supporting people living with diabetes and those at risk of skin damage. While some care plans required further review to ensure information remained fully up to date and reflective of current needs, overall records provided staff with the information needed to deliver safe and effective care.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Equipment was stored safely when not in use.

Servicing arrangements and emergency equipment had been maintained appropriately. People told us they felt safe living at the service and said they could access communal areas independently. Staff demonstrated a good understanding of environmental safety and maintenance reporting.

A recent visit from the fire service had taken place with some minor work to complete, which they were satisfied the provider would address. The registered manager confirmed work had already started to address this.

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.

The registered manager monitored staffing and training levels to make sure they had enough skilled staff. People and relatives confirmed this. A relative said, “From my observations, there are always plenty of staff. They seem well trained as they know what they’re doing.”

Staff confirmed the provider had a robust recruitment programme in place, which included interviews, checks on their suitability to work with vulnerable people and induction into the service. Staff said interviews felt robust with relevant questions being asked of them. The provider had not always kept copies of interview records, which the registered manager confirmed they would address for the future.

Staff received regular support sessions and yearly appraisals. Regular staff meetings took place to ensure staff felt well supported.

The provider assessed but had not always managed the risk of infection. They had not always detected and controlled the risk of it spreading but did share concerns with appropriate agencies promptly.

Staff used the kitchen as a throughfare to other parts of the service and did not use personal protective equipment during these occasions. We brought this to the attention of the registered manager to address.

The service was clean and tidy. However, some areas requiredpainting to ensure surfaces could be cleaned thoroughly, including radiators. The registered manager organised for this to take place immediately.

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.

Medicines were correctly ordered, stored safely and administered in line with people’s prescriptions. Some people’s medicine lists needed to be updated. Although there was no impact on people, the registered manager was going to address this. People and their relatives told us they received medicines on time and correctly. One person said, “I always get my medication on time.”

We noted the medicines policy was quite lengthy and would benefit from streamlining to improve accessibility for staff. The registered manager told us they would review this.