Seventrees 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.

This is the first assessment for this newly registered service. This key question has been rated 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 safe care and treatment at the service.

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. The provider did not always listen to concerns about safety and did not always act in response to safety events. Lessons were not always learnt to continually identify and embed good practice.

Effective systems and processes were not always in place to ensure lessons were learned and actions taken when identified by risk assessments. For example, safety actions identified in the fire risk assessment, such as to ensure all fire doors were fitted with compliant seals and hinges, had not always been completed within the recommended timescales, and safety actions identified in the legionella risk assessment were not initiated. This meant people were at increased risk of harm.

However, the provider demonstrated they wanted to learn and improve. When we raised these concerns with the provider, they took action to address the outstanding actions.

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.

The provider had systems and processes to support safe transitions between services. For example, there was typically a gradual transition process before people moved in. This included short visits, followed by an overnight stay. These visits helped people build confidence with the staff and their new environment. An initial assessment was completed, and this information was transferred into care plans and risk assessments for people and was shared with staff.

Professionals told us they had good communication with the staff, and they were confident staff knew how and when to report and escalate concerns.

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. The provider shared concerns quickly.

People and their relatives told us they were happy and they felt safe, and we observed people appearing content and relaxed with the staff. They were supported by staff who knew them well, received safeguarding training, were supported by a safeguarding policy, and who told us how they could identify and report safeguarding concerns. Safeguarding concerns raised were reported and investigated by the provider and shared with other authorities.

Where people were subject to Deprivation of Liberty Safeguards (DoLS), staff knew how to support them as people’s care plans contained information and guidance.

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.

Risks to people were not always monitored and action taken in line with their risk assessments. For example, 1 person’s risk assessment stated they were at increased risk of dehydration, and they had a recommended daily fluid intake. However, records showed this target was only met on 7 of 14 days. There was no evidence to show the person’s fluid intake levels were monitored, or action taken in response to the target not being met. This put the person at increased risk of dehydration.

However, care plans and risk assessments were reviewed and updated. This meant staff had the information to support people effectively. For example, we observed when people displayed behaviour which communicated a need, emotion or distress, staff supported them in line with their plans.

Some risks to people were assessed and actions were taken to reduce the risk of harm. For example, people who had specific medical conditions had risk assessments and staff received training in how to understand, recognise and respond to deterioration in these conditions, including when to call for medical assistance.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

We observed the environment posed avoidable risks to people. The provider did not have effective systems and processes to identify, assess, monitor and reduce environmental risks. For example, 3 doors and 1 gate on fire exit routes were locked, meaning people may have been prevented from evacuating without delay in an emergency. Some staff had not completed a fire evacuation drill, and staff told us information which conflicted with 1 person’s personal emergency evacuation plan (PEEP) about how to evacuate them to. This meant staff may not be able to effectively support the person’s evacuation in an emergency.

Radiators were unprotected, with no risk assessment to consider and reduce the risk to people from burns, despite 1 person’s risk assessments stating they were at risk from hot surfaces, including radiators.

The risk from legionnaires disease was not effectively managed. For example, water temperatures were not correctly monitored, a competent person was not appointed to manage legionella controls, and no safety actions from the legionella risk assessment were addressed. This meant people could be at risk of harm from legionella.

The provider was open and honest and acknowledged the short falls we identified. We asked for some immediate assurances during the inspection, and they took action to reduce some of the risks identified, including some of the maintenance works, training and risk assessments. However, the risk assessments were not always robust or comprehensive.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always work together well to provide safe care that met people’s individual needs.

Relatives and staff told us there were not always enough staff to supervise people. They told us there were times when staff were not available to keep people safe. For example, at times there were only 2 staff working. When these 2 staff were occupied, this left some people at risk of harm as there were no other staff present to support and supervise them. Relatives and staff also told us there were not always enough staff to support people to access the community and offsite activities were limited, because of a lack of staffing.

When we shared our concerns with the provider they told us they increased staff at specific times to improve supervision, such as at weekends to help facilitate more activities, and they made changes to the rota to provide a more balanced mix of staffing across the day and night.

During our assessment, we observed there were enough staff to keep people safe, however staff did not always take opportunities to involve people in engaging or enjoyable activities.

Staff received training appropriate to their role. This meant people received the care and support they needed. For example, staff completed training in learning disabilities and autism, moving and handling, diabetes and epilepsy.

Staff were recruited safely. There were recruitment, supervision and appraisal policies and staff recruitment records included the correct information. Where we found a small number of gaps in recruitment records during the inspection, these were immediately rectified by the provider.

The provider did not always assess or manage the risk of infection. They did not always

detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The risk of infection and cross contamination was not always identified, assessed or reduced. For example, there was no risk assessment for food stored in the laundry room. This meant there was a risk of food being contaminated from dirty laundry. We raised this with the provider, however, we have not been assured the risk has been reduced.

However, the service appeared visibly clean with no malodour. People were supported to keep the home clean, and tidy, and there was an ongoing programme of maintenance. For example, a new kitchen was recently installed.

There were systems and processes to prevent and control infection, such as staff, training, monthly cleaning audits, guidance for staff such as posters on how to wash hands effectively, and we observed staff using personal protective equipment (PPE).

The provider showed us evidence of action they took when concerns were raised about the risk of infection.

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

People’s medicines records did not always contain information staff needed to administer medicines safely. Although protocols for medicines to be taken ‘when required’ (PRN) were in place, 1 person’s records showed a PRN medication was given continuously and not on an occasional basis.

People’s records did not always have detailed guidance for staff about the use of multiple PRN medicines, and how long each should be used before referral to a health professional.

Records for the administration of medicines prescribed with variable doses were not always completed to show the doses given. This meant there was a risk people could receive too much medicine over time.

Contact staff had with health professionals about people’s medicines was not always recorded. This meant changes to medicines may not be recorded and shared between staff. This could impact on people receiving their medicine safely.

For 1 person, a known medicine sensitivity was not always recorded across their documentation. For example, it was not recorded on their medication administration record. This could lead to harm for the person.

During the inspection we observed people received their medicines safely and records we checked showed overall people received their medicines as prescribed. We observed staff administered medicines calmly, did not rush people and they ensured people had a drink to hand. However, records for the administration of medicines prescribed with variable doses did not always show the actual doses given.

The provider demonstrated an awareness of STOMP (Stopping Over Medication of People with a Learning Disability, Autism or both) and they had taken steps to reduce the unnecessary use of psychotropic medicines. For example, records showed staff worked alongside GPs and psychiatrists to review and reduce people’s medicines.

Medicines were stored safely and securely and at the correct temperatures. Staff regularly had their competence assessed around medicine management. This meant they handled and gave people their medicines safely.

The provider assessed the risks around people’s medicines and care plans contained information for staff to refer to when giving people their medicines.