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 72 (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.

Systems were in place for recording, analysing and responding to incidents and events such as safeguarding issues, complaints and accidents. Action was taken to address any shortfalls and prevent reoccurrence. A staff member said, “We are excellent at raising concerns and acting quickly by contacting GPs, DN and other professionals.”

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.

Prior to the commencement of care, the provider obtained detailed information about people’s care and support needs. This ensured care was planned appropriately and staff could provide support that reflected people’s individual requirements.

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.

Staff received training and demonstrated an understanding of their responsibilities for identifying and escalating concerns. The provider had taken appropriate action to protect people and promote their wellbeing whenever an incident or accident had occurred. This included making timely referrals to relevant healthcare professionals to ensure people received the support they needed.

Information was shared appropriately to support safe care, and people consistently told us they felt safe using the service. A person said, “I really do feel safe with them. They are a good bunch.”

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 dementia and those at risk of falls. 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 home environment by completing environmental risk assessments. They made sure equipment supported the delivery of safe care and staff had received training to support this.

Risks associated with people’s individual environments were assessed before staff started supporting people within their homes.

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 confirmed this. A person said, “I get 2 calls a day, morning and night. The staff are usually on time unless the weather is bad, but they have never not turned up.”

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 and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Staff kept people’s homes clean and tidy, even when this was not part of their care package.

Personal protective equipment was available to staff and people confirmed staff used this appropriately. A person said, “Yes they put gloves on when they are supposed to.”

The provider had not always 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 ordered, stored and administered safely in line with people’s prescriptions. However, some improvements were needed to ensure records fully reflected people’s current medicines support. This included updating some care plans, particularly for people who self-administered their medicines, and ensuring medicine risk assessments were in place and reviewed. Some medicine lists also required updating to align with best practice guidance, including clearly recording dosage information. Protocols for medicines prescribed on an ‘as required’ basis (PRN) also needed to be developed where these were not in place.

Despite these recording issues, people consistently told us they received their medicines safely and on time. One person said, “I do not know what I would do if the staff did not sort my medicines out for me. They keep me right and make sure I have them.”

Staff received competency checks to ensure they could administer medicines safely to people. Although issues with recording were found, there had been no impact on people because staff knew them well. The issues we found were discussed with the management team to address immediately.

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