Summerfield Private Residential 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. At our last assessment we rated this key question Good. At this assessment the rating has changed to 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.

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 investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Staff were encouraged to report concerns. However, some accident and incident reports were incomplete and did not explain in sufficient detail the sequence of events and how the person was found. There was no incident report for a ‘near miss’ event and no evidence of an investigation or risk review, which the provider’s accident policy stated should be undertaken.

Accident and incident reviews did not demonstrate robust or comprehensive analysis, creating potential risks to people’s safety. Investigations were largely limited to the immediate actions taken in response to the individual incident, with insufficient consideration of wider themes, patterns, or opportunities for shared learning.

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.

Systems were in place to ensure people were safely transferred between services and all information about their care and treatment needs went with them. This ensured people received continuity of care when moving either to hospital or another service.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

People told us they felt safe in the service and around other people who lived there. Staff had completed training in safeguarding adults and understood reporting processes. No safeguarding notifications had been received by CQC in the 12 months prior to this assessment. We made a safeguarding referral during the assessment relating to omissions in people’s care records, environmental risks not fully assessed and incomplete accident reports. Although people were not harmed, these shortfalls impacted on people’s safety placing them at potential risk of harm and neglect. The provider took action to address these issues during the assessment.

Staff had received training in Deprivation of Liberty Safeguards (DoLS). DoLS ensure if a person is restricted in a way that deprives them of their liberty in a care home, it is only done when it is in their best interests, is necessary for their safety, and all other options have been considered.The provider had a DoLS tracker which showed authorisations in place and monitored the progress of applications. Two people had DoLS authorisations with conditions; however, not all the conditions had been met. The provider took action to address this during the assessment.

The provider did not always work well with people to understand and manage risks.

Risk assessments were in place; however, they were not always up to date or accurate. Risks to people were not always identified by staff or acted on. For example, we found people did not have access to call bells in some communal areas and bedrooms as there was either no call bell point or no call bell leads available. Where bed rails were in use, risks had not been fully assessed, and bumpers were not always in place. The provider took action to address these issues during the assessment.

Children related to staff were present in the service on both site visit days and on occasions were left unsupervised. The potential risks posed to both the children and people living at the service had not been identified by the provider. When we raised this, a risk assessment was carried out immediately to ensure everyone’s safety.

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

Safety certificates were in place to ensure the safety of the building, equipment and technology. Health and safety compliance checks were completed; however these were not always thorough. For example, bed rail checks only recorded where bed rails were in use. There was no evidence to show what had been checked and no reference to protective bumpers to prevent entrapment in the bed rails.

Environmental risks had not been identified or assessed in relation to staircases in the home which had unrestricted access. Records showed a person had recently walked down the stairs from their bedroom and had reached the dining room before staff were able to respond to the sensor alert. The person’s care plans showed their mobility was poor and they were at high risk of falls. Records showed there had been 2 other incidents in May when the person had accessed the stairs. However, there were no incident reports for these ‘near miss’ events and no evidence of a risk review. There was a risk assessment in place for the staircases,however this had not been reviewed following these incidents.

Fire safety checks were up to date. Emergency information was available, however, information in personal emergency evacuation plans (PEEPs) was not accurate or up to date. For example, there was no PEEP for 2 people and room numbers were not correct for some people. The provider took action to address this during the assessment.

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.

The provider used a dependency tool to calculate safe staffing levels and rotas showed these levels were maintained. Overall people and relatives felt there were enough staff. Our observations showed staff checking on people in communal areas, as well as those who chose to stay in their rooms. Safe recruitment processes were in place, including induction and shadowing. Mandatory and specialised training was provided to staff and kept updated.

The provider assessed and managed the risk of infection.

Effective infection prevention and control processes in place and good standards of cleanliness were maintained throughout the home. Staff were provided with, and observed using, personal protective equipment (PPE) appropriately.

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

Medicines were stored safely and securely with appropriate temperature monitoring. Electronic medicines administration records (eMARs) were completed appropriately, and people received their medicines as prescribed.

Some people were prescribed medicines to be administered ‘when required’. However, there were no protocols in place on the eMAR system to guide staff in how and when these medicines should be given.

Topical medicine administration records (TMARs) were completed by care staff when creams were applied. However, we found multiple gaps on the TMARs where staff had not signed and therefore, we could not be sure creams had been administered. Body maps were in place; however clearer guidance was required to show where on the body creams should be applied and how often.

The provider took action to address these issues during our assessment.

Monthly medicine audits were completed; however they had not identified the issues we found.