Tower Bridge 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 inspection for this 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 infection prevention and control.

This service scored 59 (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. Staff did not always listen to concerns about safety and did not always investigate and report safety events. We received mixed feedback from people feeling comfortable about raising concerns. One person said, “If there was something I wasn’t happy about I would feel comfortable saying something. I have spoken with [staff] before and things are always dealt with straight away.”

However, we also received feedback from people saying they do not report things as they are worried about possible comebacks. One person said, “If you say anything about the care, they think you are criticising them.” The feedback indicated staff did not always listen to people’s concerns, therefore preventing lessons being learned and putting increasing the risk of avoidable harm to people.

The provider had policies and procedures in place for managing safety of people and the building. Accidents and incidents were recorded, and management took action to prevent repetition. The service had daily meetings with staff, to discuss all aspects of the service, including accidents, complaints and suggestions for improvement. Staff had received training in safeguarding people.

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 moving into the service, people and their relatives were encouraged to visit the service to see if it was somewhere they would like to stay before a commitment was made to deliver care. People told us they were happy with the referral process, and they were involved in the planning and reviewing of their care plans. People had hospital passports in place which ensured health care services had good access to relevant information to support people. Healthcare professionals told us they worked well with the service, and the service was always able to provide information relevant to people’s support needs as required.

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. The provider shared concerns quickly and appropriately. Deprivation of Liberty Safeguards were (DoLS) were completed as required. People told us they felt safe around staff. One person said, “[Staff] have said to me not to be afraid, and to let them know if I am worried about anything.” Relatives told us, they were confident if they raised a concern appropriate action would be taken. One person told us, “It is safe, we are satisfied with things, and we think it is a good place for our relative.” Staff told us they felt comfortable raising concerns with the management team if required. The provider had safeguarding policies in place, and staff had received mandatory training in safeguarding adults, which was mandatory for them to attend each year.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care which was supportive and enabled people to do the things that mattered to them. Some risk assessments did not have enough evidence-based information to inform staff on how to keep people safe. For example, risk assessments for people with diabetes did not refer to monitoring of glucose levels although people were being administered insulin daily. We discussed this with the management team, and were told reviews for this were completed annually. However, this left people at risk of receiving treatment that was not appropriate because staff would not be aware if people’s needs had changed due to inadequate monitoring. Staff did not always respond to people’s needs in a positive way. Some people told us their risk of them becoming isolated due to their condition was not managed well. We received comments like, “I need a lot of support, it’s not good for me to be in the same position all day. [Staff] do get impatient with me, but I know they are busy, and they have a lot to do,” and “I feel a bit isolated here, but the staff do their best.” This meant some people were left at the risk of isolation and the risk of avoidable harm to people’s wellbeing and health.

People and their relatives told us they were involved in the planning and reviewing of their care plans and risk assessments, and they were happy with how this was done. Care plans and risk assessments covered all people’s health and nutrition needs.

The provider did not always effectively control potential risks in the care environment. The service had an ongoing issue with mice. People told us they saw mice in their bedrooms in the evenings. One relative said “The main issue is the mice running around the bedroom. We have been told they cannot put anything on floor because residents may eat it, but that a strange thing to say.” We discussed the issue of mice in the building with the management team who told us they had seen an improvement in the number of mice seen in the building, and they were working with a reputable pest control company to try to resolve this issue. This issue increases the risk of infection and bacteria in the home, putting people at an increased risk harm and avoidable harm. However, the service appeared clean, well designed and well presented. The rooms had lots of space, and some bedrooms were personalised. The service had safe flooring throughout. The corridors were wide enough for wheelchairs to be manoeuvred down safely. There were handrails running along the corridors, so people were able use this for support if required. Fire exits were clearly marked with no obstructions in front of fire doors. People had personal emergency evacuation plans in place as required. Documents showed that equipment and facilities were checked for safety and checks were up to date.

The provider did not always make sure there were enough qualified, skilled and experienced staff available to meet people’s needs. A professional we spoke to said they felt there was not continuity of good care across all floors, and some staff lacked knowledge and confidence of how to support people well.

People gave mixed feedback as to whether they thought there was enough staff in the service. We received comments like, “I use the call bell and [staff] come as soon as they can. At nighttime there are staff who check in on me, the door is left ajar so they can hear you if you call out.” Another person said, “They are short of staff, I think. They are quite rushed, and they can get a little impatient. They do not have time to talk. I try not to use the call bell too much I prefer not to. Concerns with staff left people at the risk of avoidable harm in relation to the number of staff available to support people when needed, and the ability of staff to support people with confidence.

The provider had a good recruitment process in place. The recruitment files we reviewed showed staff had application forms, appropriate photo id, right to work in the UK and Disclosure and Baring Services (DBS) checks in place. Staff had provided full employment histories and work references to ensure recruitment was safe. Staff received an induction at the beginning of their employment, that was relevant to their role to keep people safe. Staff told us they were happy working with the service, and they felt supported by the registered manager. Healthcare professionals we spoke to gave positive feedback about staff at the service and found them supportive and committed to providing good care.

The provider did not always manage the risk of infection effectively. We viewed a pest control report which showed mice droppings beneath kitchen cupboards in the service. The registered manager arranged for an increase in the visits from the pest control team. The registered manager also arranged an urgent meeting with the quality team to draft an action plan designed to address the ongoing issue.

The management team told us they ensure there is an overstock of PPE for staff to use, and staff confirmed they have no issues with accessing PPE on a daily basis. People also told us that staff always used PPE as appropriate. The provider had an infection, prevention and control policy in place for staff to follow. At the inspection, the service appeared to be clean, and there were no obvious malodours. People and their relatives told us they thought the service was very clean. We received comments like, “The cleaning is very good, [staff] wear gloves when they need to,” and “The [staff] all wear gloves and aprons when dealing with you,” and “Most of the time it looks clean, there are moments when it might be a bit untidy.” And “It always looks clean when I visit.”

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 told us they had no issues with how the service managed their medicines. We received comments like, “The medicine is all done well and [staff] make sure you take it, I am aware of what I take,” and “Once or twice a year they go through my medication in the care plan. I sign it and its done. [Staff] are always in touch if my relative is not well.” The provider had a robust medicine policy in place information staff how to ensure medicines were delivered and managed safely. Medicines were locked in a secure cupboard and keys were with staff allocated to administer medicines. The fridge used for medicines was cleaned and used for medicines only. The temperature was monitored and recorded appropriately. Medicines given was recorded on an electronic system which worked to reduce the risk of error. At the time of the inspection the audit showed the medicines recorded as being in the service on the system, and medicines on site were accurately tallied. Staff who administered medicines had ongoing yearly competence checks, and a monthly audit was completed by the registered manager.