Sandstone Brook

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 69 (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.

The provider had a positive culture of learning from incidents and concerns to improve practices at the home. Effective systems provided oversight of incidents, accidents and safeguarding concerns, including investigation records, actions taken and lessons learned. The regional manager and provider had access to incident information, which enabled timely reviews and support. Incidents were discussed at the provider’s quality meetings to review trends and drive improvement. For example, following an incident where a person left the service with a visitor, the provider strengthened safeguards by including Herbert Protocol checks within care plan audits and installing a keypad entry system on the main door. The Herbert Protocol is a tool designed to help police and emergency services quickly locate someone with dementia if they go missing. A fault with the CCTV system was also identified and rectified. This demonstrated how learning was used to improve safety and reduce the risk of recurrence.

Staff demonstrated an understanding of lessons learned from incidents and how this influenced practice. One staff member told us, “We do get informed if people have fallen and sometimes, it means we have to support them in a different way or use different equipment.” This demonstrated learning was effectively shared with staff, enabling support arrangements to be adapted to better meet people’s needs and promote their safety.

The registered manager demonstrated compliance with Duty of Candour. Following incidents, people and, where appropriate, their relatives were informed promptly, kept updated on the progress of investigations, and provided with the outcomes. This ensured families were appropriately informed, involved and supported throughout the process.
 

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.

People experienced safe, coordinated care because there were effective systems in place to support referrals and transitions between services. Staff worked with external health and social care professionals to ensure people received timely assessments, treatment and support when their needs changed. Information was shared appropriately and in a timely manner to promote continuity of care and safety.

When people moved into, within, or from the service, there were clear transition arrangements in place which considered their individual needs, preferences and risks. The home had a ‘resident experience manager’ whose role was to support people and their families when they first moved into the home. Staff understood their roles and responsibilities in supporting safe transitions and helped people to experience positive outcomes. These arrangements helped to reduce the risk of people experiencing unnecessary disruption or unmet safety needs during periods of change.
 

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 because effective safeguarding arrangements were in place. People felt safe at the home and one person told us, “I feel safe because I am not on my own now and help is there.”

Staff understood their responsibility to recognise, report and escalate concerns and were confident appropriate action would be taken. One staff member told us, “If I had any concerns that abuse was occurring, I would inform management immediately. If I felt management weren't taking any action, I would escalate it to senior management or report it directly to CQC.” This demonstrated staff understood safeguarding procedures and felt confident to raise concerns, helping to protect people from the risk of harm.

People's rights were also protected through the appropriate use of the Deprivation of Liberty Safeguards (DoLS). Staff understood how restrictions on people's liberty should be applied lawfully and in their best interests to keep them safe. The registered manager demonstrated a good understanding of their responsibilities under DoLS, including recent legislative developments and their impact on future applications. They confirmed and we saw authorised restrictions were in place where required and were kept under review. The registered manager provided an example of a person who had previously required a DoLS authorisation but, following review, no longer met the criteria for deprivation of liberty. This demonstrated the provider worked proactively with the local authority to ensure any restrictions remained necessary and proportionate, while promoting people's rights, freedom and wellbeing.
 

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’s risks had been assessed and were managed by individual risk assessments. These risk assessments, along with care plans, provided staff with clear guidance on how to help reduce the risks to people and keep them safe.

Staff balanced risk management with promoting people’s choice and freedom to keep them safe. For one person, a detailed smoking risk assessment and best interest decision ensured risks were managed safely while supporting the person in the least restrictive way and upholding their rights and choices.

People had an individual personal emergency evacuation plan (PEEP), which detailed the level of support they would need to leave the building in an emergency. This also included controlled and emergency evacuation plans.
 

The provider did not always detect and control potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Records showed required safety checks of equipment and utilities had been completed.

People lived in a safe, clean, and well-maintained environment. Corridors were wide and had handrails, and bathrooms and toilets were designed for people with mobility problems. People were encouraged to personalise their own rooms.

During the assessment, we noted a food warming plate on 1 unit had been left switched on in an unattended dining area. Staff told us the hot plates should only be switched on shortly before meals and supervised at all times when in use. Following our feedback, the registered manager implemented increased checks and purchased guards to prevent access to hot surfaces.Following our assessment, the registered manager confirmed hotplate screens had been fixed to all hotplates.We also found 2 storage rooms where cleaning products, which could cause harm to health, were not stored securely. The rooms were unlocked and the cupboards holding the cleaning products were also unlocked. This posed a risk to people and visitors who would have access to these potentially harmful substances. When rechecked later in the day, these cupboards had been secured. The registered manager took immediate action by increasing monitoring and fitting keypad locks to these storage areas. Because immediate action was taken, the risk to people was reduced and we were satisfied people were protected from any potential harm after we had bought it to attention of the registered manager.

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, relatives and staff consistently told us there were enough staff available to meet people's needs, and our observations supported this. People told us they received support when they needed it, and we saw staff responding promptly and spending meaningful time with people. One person told us, “The staff are well trained and know what I need.”

Staff told us staffing levels were sufficient to provide safe care and positive outcomes, even during busier periods. One staff member told us, “It can be busy, but we are able to give people quality time.”

Safe recruitment practices were in place to help ensure suitable staff were employed. Pre-employment checks were carried out on new staff, including verification of references, right to work and enhanced Disclosure and Barring Service (DBS) checks.

The provider had recently introduced a workplace induction co-ordinator role to support new staff through their induction and onboarding. Staff spoke positively about this approach and told us they felt well supported whilst developing their skills and knowledge. One staff member told us, "The induction was really good. The induction co-ordinator met with me every week to check how I was doing and whether I needed any additional learning." They added the staff team was supportive, and they never felt rushed or under pressure while learning their role. This demonstrated the provider's commitment to ensuring staff were safely recruited, supported and prepared to meet people's needs.
 

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.

However, we saw a person had their eye drops administered without the staff member washing their hands beforehand. This was not consistent with best practice for reducing the risk of infection transmission and has potential to cause harm to the person. We shared this with the registered manager at the time of the assessment who told us they would review staff practices.

The provider's cleaning arrangements at the home and a dedicated housekeeping team helped to keep people protected from the risk of infection. Good practice made sure the environment, including people's rooms, were clean and hygienic. There were handwashing facilities throughout the building and access to hand sanitiser. Staff had attended training in infection prevention and control (IPC) and wore personal protective equipment (PPE) when required.
 

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 and relatives told us staff ensured they received their medicines when they needed them and staff told them what they were for.

People’s medicines were managed and stored safely. Some people had their medicines ‘as required’ rather than being given at specific times. Protocols were in place to inform staff of the signs and symptoms which would trigger administration, what dose to administer and how often. Body maps were in place to inform staff where people’s topical medicines should be applied.

Staff were medicines trained and their competency was assessed before they were allowed to administer. Staff competencies were re-assessed following long periods of absence or if the staff member had a series of medicine errors. Any staff member involved in a medicine error was required to write a reflective piece on the incident, and medicine related incidents were reviewed closely by managers, with learning shared with staff.

An electronic medicine recording system automatically flagged any missed or delayed medicines. This is especially important for people who require time sensitive medicines, such as people with Parkinson’s Disease. Managers reviewed this data and it was collated for analysis and to identify any trends.