Northfield 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. At our last assessment we rated this key question good. 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 service was in breach of legal regulation in relation to people’s safe care and treatment.
 

This service scored 56 (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 systems in place to report, investigate and review accidents and incidents, and there was evidence that learning was identified and shared. For example, falls analysis was undertaken to support monitoring and help reduce future risks. People and relatives told us they felt able to raise concerns and were confident these would be acted upon. Staff understood the process for reporting and managing incidents and accidents. However, safeguarding information was not always up to date or accurately recorded. This meant the provider could not be assured that all safeguarding concerns were effectively reviewed, monitored, or used to identify wider themes and trends. As a result, opportunities to learn from safeguarding incidents and embed improvements across the service may have been missed.

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.
Staff recognised changes promptly, followed guidance and worked with healthcare professionals so appropriate action was taken.
For example, when a person became unwell, staff spotted early deterioration, followed escalation procedures and contacted emergency services. They informed relevant people, completed extra monitoring and supported the person’s recovery after hospital assessment.

The provider had not always ensured people were protected from avoidable harm. Shortfalls in monitoring safeguarding meant risks were not always understood, assessed or acted on promptly.
Records did not always show that action was taken promptly in response to concerns about people’s safety and wellbeing. Safeguarding concerns were reported to the management team, but follow-up actions and monitoring were not consistently recorded or reviewed. Staff had completed safeguarding training and understood safeguarding principles, but management oversight did not always ensure people were protected from known risks.
People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that leaders demonstrated a clear understanding of when people may be subject to Deprivation of Liberty Safeguards (DoLS), and we saw that appropriate applications had been made. Leaders maintained oversight of DoLS applications that had not yet been granted. Any restrictions authorised under DoLS were clearly identified and followed by both leaders and staff. However,decision-specific mental capacity assessments and associated decision-making records were not always in place where required. For example, while capacity assessments were in place for some decisions, including those relating to finances, appropriate assessments were not consistently in place for other decisions, including those relating to medicines.

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. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Care records did not always contain consistent or detailed information on risks to people. For example, one person’s records had contradicting information on how to support people with medicine and 2 other people information on their dietary support had not been shared with kitchen staff.

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.
We found areas of the home required attention to ensure people’s safety. For example, there were a fire door wedged open, and an area that should have been locked was left accessible. Following our visit the provider addressed the areas, and they have assured us the improvements would continue.
The provider was in the process of completing re-refurbishment works and re-decoration at the service. New furniture and flooring had been supplied in some areas. They had an extensive environmental action plan, with ongoing work in progress.
 

The provider did not always ensure there were enough suitably skilled, competent and experienced staff deployed to meet people's needs safely and effectively. Feedback from people and their relatives highlighted concerns regarding staffing levels, particularly at weekends and during mealtimes. They told us staff were often busy, unavailable, or people experienced delays in receiving support. Review of the service's staffing dependency tool and staffing rotas identified a high reliance on agency staff. Staff told us this sometimes impacted continuity of care, particularly during night shifts, and one member of staff described some shifts as "carnage" due to staffing pressures and the use of agency workers. One staff said, “If there were more staff there wouldn’t be so many falls, and its chaos on the middle floor everything is rushed.”

Whilst staff were observed supporting people who required one-to-one support, we found the provider could not always demonstrate effective oversight of staff competence. For example, competency assessments relating to the administration of rescue medicines were not being completed, and training had not always been delivered in line with the provider's policy. The provider took prompt action to address this once highlighted to them.However, most staff had received mandatory training and regular supervision. Clinical oversight arrangements were in place, staff were recruited safely, and appropriate recruitment and induction processes helped ensure new staff were supported to undertake their roles.

The provider did not always assess and manage the risk of infection effectively. Whilst most areas of the home were clean and tidy, we identified several areas requiring more thorough cleaning, including crash mats, equipment, skirting boards and extractor fans. There was a malodour present on both floors of the home. During the assessment, we observed some staff wearing rings and stone-set jewellery, which was not consistent with good infection prevention and control practice. Although records showed that environmental walkaround checks were being completed, these had not identified a number of the concerns found during the assessment, indicating that oversight systems were not always effective in identifying and addressing environmental risks.
However, housekeeping staff were visible throughout the assessment and were responsive to concerns raised. The provider advised they were replacing carpets with flooring that could be more effectively cleaned and maintained, demonstrating action being taken to improve infection prevention and control arrangements within the service.

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. People’s medicine’s records showed that they received their medicines safely and as prescribed. Staff were knowledgeable about people and their medicines.
There were suitable arrangements for ordering, and disposal and those requiring extra security. Suitable temperature monitoring was carried out to make sure medicines were safe and effective. Storage of creams and thickening agents needed to improve however immediate action was taken.