Cuttlebrook Hall

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 78 (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 strong proactive and positive culture of safety, based on openness and complete honesty. Staff actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice.

There was a strong focus on using incidents as learning opportunities, with an emphasis on identifying themes or trends and taking action to prevent them from happening again. For example, 1 person living with dementia experienced several falls within a short period of time. In response, the registered manager arranged for staff to attend a dementia and falls workshop. The workshop explored how to support people with dementia safely, how dementia can contribute to an increased risk of falls and reviewed a range of case studies. This helped staff develop a better understanding of how different types of dementia affect people and what strategies can be used to reduce the likelihood of further falls.

Lessons learnt were consistently completed for all accidents and incidents, and these were routinely shared with staff through an internal bulletin, during daily handovers and in team meetings. This created a strong learning culture where staff were encouraged to reflect on events and understand how improvements could be made. By reviewing incidents collectively and promoting open discussion, the provider ensured learning was embedded across the team and supported continuous improvement.

The provider arranged for staff to attend bespoke practical falls prevention training in response to an increase in falls within the home. The training focused on discussing recent falls that had occurred and encouraged staff to reflect on the circumstances surrounding each incident to identify how they could be prevented from recurring. By using real events from within the home, staff were able to explore contributing factors, understand patterns, and consider practical strategies to reduce risk. This approach demonstrated a strong learning culture where incidents were used as an opportunity to develop staff skills, improve practice and enhance people’s safety.

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 admission into the home, an initial assessment was completed. Where possible, this was completed face to face to ensure the provider could meet the persons’ assessed needs. The person completing the assessment asked questions about people’s particular interests. For example, one person showed a particular interest in books, the provider made sure there were books in their room for when they moved into the home. People told us the provider encouraged them to visit the home. Comments included, “I came on 3 visits here before deciding to move here. They walked me around and they answered all my questions,” and “When I looked around, the manager was so helpful. [Staff member] too was particularly good and answered all my questions and [they] stressed that I could ask about any aspect at all.”

The service worked collaboratively with external partners and professionals to ensure people had a safe admission to the service, or when people experienced a hospital admission. Relatives told us, “Our experience has been fantastic in all respects, [person] has had a couple of falls at the home and had to go to hospital but the staff made it a nice easy transition when[person] returned, everyone did a wonderful job,” and, “[Person] moved in and [registered manager] was instrumental in arranging the transfer from hospital.” Another relative told us, “We were looking for a home that could provide a high level of care. We liked the ethos, the structure, the rooms, the gardens, the private garden space, the café, the pub, the cinema, the bistro and the meeting places. They all worked so well for [person] and also there was the necessary care level and a focus on dementia care. For [person], the experience has been nothing less than excellent, it is a difficult time for [person] and the family.”

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 and appropriately.

People were protected from the risk of abuse and avoidable harm. All staff received regular safeguarding training. Staff had a clear understanding of their responsibility to report any safeguarding concerns. Staff we spoke with told us, “I learned as a carer I have a duty of care to safeguard the people in the home. I learnt what my responsibilities are, how to report, who to report to, which is [the registered manager.] Another told us, “I would report anything that affects a resident’s safety, dignity or wellbeing, this includes safeguarding concerns like signs of physical, emotional, sexual, or financial abuse, accidents and incidents such as falls, injuries or near misses and any medication errors. I would first make sure the resident was safe and then report it straight away to the home manager.”

At the beginning of each shift a daily handover sheet was given to staff during handover. Daily handover meetings were used to share information and ensure any new risks or safeguarding issues were communicated to staff promptly.

The registered manager had reported safeguarding concerns to the relevant local authority and had notified the Care Quality Commission by submitting the required statutory notification.

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 and their relatives told us they were actively involved in planning how risks were managed to keep people safe. Risk assessments were regularly reviewed and promptly updated when people’s needs changed. People with specific health risks were supported effectively to reduce the likelihood of avoidable harm. For example, a person with epilepsy had a seizure risk assessment in place, providing staff guidance on how to support that person if they had a seizure. Risk assessments contained clear guidance on how risks should be mitigated. One relative told us, “Cuttlebrook Hall have monitored [person’s] food and managed the risk of choking, [person] gets non choking food now. They recognised that and managed it very well.”

The provider also supported people to take positive risks safely. For example, one person chose to smoke, and staff worked with them to ensure this could be done as safely as possible. They provided appropriate aids such as a smoking blanket and a personal alarm and adapted the outdoor environment to reduce risk. The provider also supported the person to increase their mobility by attending exercise classes within the home, building strength and stamina. As a result, the person was able to access the smoking area independently.

People’s wishes were considered when completing risk assessments, ensuring decisions reflected what mattered most to them. For example, one person wanted to become more independent with their mobility and walk outside without supervision. Staff worked with them to assess the risks and put appropriate measures in place to support this safely. This was another example of how positive risk taking was encouraged in line with people’s desired outcomes.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

There were appropriate checks in place to ensure the home was safe and well maintained. Logs in place actioned when maintenance tasks had been completed, and daily environmental checks were carried out. Staff received effective training around fire safety, fire drills were carried out regularly and records demonstrated actions and improvements required which were followed up on the next fire drill.

The home incorporated safety features consistent with Health and Safety Executive (HSE) guidance to protect people. Windows were fitted with restrictors and specialist equipment such as falls sensors and air mattresses were in place and well maintained where required.

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.

People and their relatives told us there were enough staff available to meet their needs. Comments included, “For us, when we go in, there is always someone to talk to you, they always find someone of the appropriate level to talk with you,” and “I think there are always enough carers, they are good staff too.”

Staff mostly felt there were enough staff to meet people’s needs. One staff member told us, “Staffing is generally safe and we are able to meet resident’s needs, there are busier times of the day such as the mornings as residents all tend to wake up at a similar time and the care staff are assisting with personal care and medication is being given. During these times we do work as a team and the staff are allocated to different jobs. If I felt the staffing was unsafe, I would raise this with my manager.” Another staff member told us, “The staffing levels have got better. The main improvement was when the agency staff stopped. When I first started, we had a lot more agency staff, Care UK then said we won’t use them anymore. Things improved over night. We became aware of our resident’s needs, we knew our residents better and our colleagues.”

Recruitment checks were carried out by the provider to ensure staff were safe to work with people. Pre-employment checks included a job application form, an interview, and references. All staff were required to complete an enhanced Disclosure and Barring Service (DBS) check before starting employment. A DBS check provided information about any convictions and cautions held by police.

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.

The provider maintained a high standard of cleanliness and infection prevention throughout the building. People lived in a clean, comfortable, and well-presented environment that was free from odours. One relative told us, “It is really nice, it is new, there are no rough edges, and it smells lovely too.”

Records showed the provider had systems in place to monitor and manage the cleanliness of the environment. Regular checks and cleaning audits were completed, and any issues identified were promptly addressed.

All staff completed infection control training. During inspection, we observed staff wearing personal protective equipment (PPE) such as gloves and aprons.

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 well managed. Checks were carried out daily on stock checks and temperatures and people had guidance in place on how they would like to take their medicines. People’s independence around medicines was promoted where possible. For example, 1 person was being supported by staff who administered their medicines, however they identified they wanted to self-administer a medicine they took as this was important to them. The home organised for the district nurse to come in and train the person to safely administer the medicine, and staff observed and supported them to do so safely.