Stone Barton Short Break

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.

Records showed incident analysis, lessons learnt newsletters and governance discussions were used to share learning across the service. Staff told us they had regular supervisions, spot checks and team meetings where they discussed improvements and how to make care safer. One staff member said, “We do discuss things about improving things and making things better in supervisions and meetings.”

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.

We saw records of handovers, hospital passports, body maps and inventories completed when people arrived for each stay, and relatives valued communication books and daily updates.

Relatives were positive about the support the service provided when people move into the service. Comments included, “I can’t praise the service enough. They are exceptional. They let me know everything day and night. This is the first time I feel OK with sending (Person’s name) to overnight respite. We have tried others in the past”, and “I have a good relationship with the manager. We had a transition day and a test run with a waking night. It was really good.”

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.

Staff understood safeguarding and whistleblowing procedures and could describe how to report concerns internally and externally.

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 saw appropriate applications referred to the local authority.

Relatives told us their family member was safe and well supported. However, 1 relative’s feedback explained concerns in relation to unexplained bruising, inconsistent body maps. We discussed this with the service who had raised appropriate referrals following concerns raised by the relative and they identified improvements in their processes which were cascaded to staff.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs which was safe, supportive and enabled people to do the things that mattered to them.

We saw detailed person-centred assessments covering areas such as epilepsy, PEG feeding, choking, skin integrity, moving and handling.

Staff described encouraging people to do as much as possible for themselves and using pictures, objects of reference and simple language to support choice. One staff member told us, “Care plans are up to date, and I have access to them.”

The provider did not always detect and control potential risks in the care environment.

Some environmental risk assessments were overdue for review. We also identified some weekly fire tests had not been completed in line with the service systems and national guidance. We discussed this with the registered manager who told us, they were in the process of implementing a new system and would discuss the important of fire testing with the staff. Overall systems to monitor environmental safety were established and mostly effective. The home was tidy and had clear signage, such as easy-read fire evacuation information. We saw evidence of legionella checks, equipment maintenance, gas safety checks, bed rail checks, hoist and sling checks.

A staff member told us, “I work closely with service users, families, and colleagues to ensure a safe, supportive and person-centred environment.”

A relative told us, “The layout is lovely. They make sure (Person’s Name) has all the lights and everything in their rooms.”

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.

Staffing rotas showed enough staff to support people on a one-to-one basis, and relatives told us there was mostly enough staff.

Staff received supervisions, appraisals, spot checks and competency assessments, and many told us training was relevant to people’s needs. One staff member told us, “We are highly supported with all required training, we do face to face training and online courses. We also do refresher courses as and when due.”

Safe recruitment practices were being followed. Staff had references and Disclosure and Barring service (DBS) checks, as required. DBS checks provide information, including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. However, 2 staff files showed right-to-work dates requiring follow-up. We raised this with the registered manager, who took immediate follow up action to demonstrate up to date right- to- work.

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.

We observed the home was clean and tidy, with no offensive odours.

Cleaning schedules covered bedrooms, bathrooms, shared areas, kitchen equipment and high-touch surfaces. Staff demonstrated good practice with personal protective equipment (PPE) and hand hygiene, and relatives and staff confirmed PPE was available and used appropriately. Infection prevention and control policies and audits were up to date and followed.

Relatives told us the service was clean, comments include, “It is clean and tidy and there is a large garden”, and “It is spotless.”

The provider always made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff always involved people in planning, including when changes happened.

The systems, combined with staff competence, clear processes and positive feedback, showed the service consistently provided safe, effective and person-centred medicines management. Medicines were stored securely, signed in and out appropriately when people attended the service, and administered in line with professional guidance always using clear witnessing arrangements. The registered manager had been proactive with implementing an innovative way to monitor liquid medication without increasing the risk of waste. Monthly medication audits were completed with no concerns identified with staff administration and stock, demonstrating strong oversight and continuous monitoring. The service had identified and was in the process of ordering further equipment which was needed for the temperature control of the storage units.

Staff consistently reported they were highly trained and competent in medicines management, including delegated healthcare tasks, and felt confident to seek support where needed. One staff member told us, “I feel confident carrying out delegated nursing tasks because I have the right training and support.”

Feedback from relatives was overwhelmingly positive, with many describing medicines management as ‘really good’ and highlighting staff followed routines carefully.

Observations confirmed medicines were administered at the correct times and in line with prescribing guidance.