Stratford Bentley 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.

At our last assessment we rated this key question good. At this assessment the rating has remained 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.

Accidents and incidents were recorded and reported by staff. Accident and incident forms were reviewed by the registered manager to ensure appropriate action had been taken to keep people safe and to identify any areas for learning or improvement. Where necessary, proactive measures were introduced to mitigate risks to people. For example, the introduction of sensor mats or alarms for people at high risk of falls.

Staff told us there was a learning culture in the home which made them confident to own any mistakes. One staff member told us, “Honesty is the best policy. If we have done something wrong, we go and see the nurse or the manager so it can be rectified quickly, and you will be shown how to put it right." Another staff member commented, “We have lessons learned and everybody has to read them and then sign to say they have understood."

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.

The registered manager was proactive in supporting safe transitions as people moved to and from Stratford Bentley Care Centre. They carried out face to face assessments before people moved to the home and encouraged other providers to visit people before they transitioned into their care. The registered manager explained, “I have had situations when we have not always been given an accurate assessment of someone's needs, so I want to make sure we have all the information because people need to be looked after appropriately."

Staff were aware of scheduled appointments and ensured information was accurate, up to date, and reflective of each person’s clinical and care needs. One healthcare professional told us, “When reviewing residents, we rely upon up-to-date information from the staff and carers to enable us to make precise diagnoses and treatment plans. Before we assess residents, we always get a verbal handover from the nurse in charge.” Healthcare professionals recorded their advice in people’s records which helped to maintain safe systems of care.

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 told us they felt safe and comfortable with the staff providing their care. Comments included: “I feel safe as they are forever in and out checking on me day and night”, “I feel safe as I am not on my own” and “Staff are very nice, and they are good to everyone.”

Staff received annual safeguarding training and had a good understanding of their responsibility to keep people safe from abuse, harm or discrimination. Staff knew how to report any safety issues and were assured their concerns would be thoroughly investigated and responded to. However, staff said they would not hesitate to escalate their concerns if they felt action had not been taken to keep people safe. Comments included: "I would bring it back up and then I would take it to the next higher level, the CQC, I would have no qualms about it" and "I would speak to the manager and if she did not do anything about it, I would take it higher and make a report to safeguarding or speak to the owner (provider)."

The registered manager had raised safeguarding alerts with the local authority safeguarding team when concerns of potential abuse had been raised. Where necessary, investigations had been completed to ensure people were protected from the risk of harm.

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. Where people had restrictions in their care plans, they had been assessed as not having the capacity to consent to, the provider ensured DoLS applications had been submitted to the relevant supervisory body.

The provider worked well with people to understand and manage risks. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. However, some observed risk management strategies needed to be embedded in the written risk management plans.

People did not share any concerns about how risks to their health were managed. One person told us, “I feel safe when they hoist me from the bed to the chair and vice versa.”

Risks to people’s care were assessed and reviewed and there was generally clear guidance for staff on how to provide safe care to mitigate those risks. However, we found care plans for the management of oxygen therapy and catheter care required more detail to reflect the support required to minimise associated risks. Despite the lack of detail in these care plans, our observations and conversations with staff demonstrated they were working in accordance with best practice in these areas. The registered manager immediately reviewed the care plans and added more detail to support the practice observed.

Where possible, people were involved in developing plans to manage risks without limiting their independence. The registered manager explained, “We try and give verbal advice. Previously we had a gentleman who probably needed the assistance of 1 but he wanted to be independent. We advise people but if they have capacity, we respect that independence."

The nursing team met regularly with the registered manager to discuss any risks around each person’s clinical needs. Where any escalation in risk was identified, this was recorded and actions implemented to mitigate that risk.

The provider did not always detect and control potential risks in the care environment. However, they made sure equipment, facilities and technology supported the delivery of safe care.

Stratford Bentley Care Centre was purpose built and well presented. Maintenance staff completed environmental checks that included water quality and fire safety. However, recent issues with the heating system meant over the previous few weeks, the temperature of the hot water from some taps exceeded safe limits. The provider told us the heating system had been repaired the day before our inspection. The maintenance person took immediate action to check water temperatures were in safe limits to reduce the risk of scalds to people.

Areas of the building which needed to be secured to meet people’s safety needs were not always appropriately secured. We found some doors with stickers that said ‘keep locked’ were left unlocked. In 1 unlocked cupboard, we found liquid chemicals and, in another cupboard, access to pipework and electrical circuitry. The registered manager assured us they would make sure these doors were secured to protect people from risk. We saw prescribed thickener (used to thicken some people’s fluids to reduce risk of choking) was not always stored securely. Before we left, the registered manager removed these items and placed them in secure storage.

The provider told us of recent improvements and renovations that made the home feel more homely and visually appealing.

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.

Overall, people and their relatives felt there were enough staff with the appropriate training to meet their needs. Comments included: “At the moment there seem to be enough staff, I don’t have to wait long if I need someone” and “I think there is plenty of staff to meet my needs.” A relative commented, “The staff know what they are doing when they are looking after [Name]. I think that they are trained well.” However, some people felt staff could be rushed at busier times of the day.

The registered manager reviewed staffing levels to make sure there were enough staff to meet people’s assessed needs. If people needed additional support, the registered manager increased staffing levels to ensure people continued to receive safe and effective care. Staff we spoke with felt there were enough staff to provide the support outlined in people’s care plans and in a way people preferred. One staff member told us, “Obviously there are some busy days, but it is okay." Another member of staff commented, “Everyone knows what they have to do and works as a team.”

Staff received regular training to maintain their skills and the registered manager considered the skill mix of staff when planning work rotas. This ensured staff on duty had the skills and knowledge to complement each other and allow for the delivery of safe care.

Systems to check the suitability of staff before they commenced employment were effective. The provider made sure all safe recruitment checks were made and recorded. New staff were supported through an induction process.

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.

People and their relatives were complimentary about the cleanliness of the home. One person told us, “It is very clean here; they are always cleaning.” Another person said, “If something is spilled, they clean it up straight away.”

The environment was clean and personal protective equipment (PPE) stations were stocked and available throughout the home. We saw staff used the appropriate PPE at the required times.

All staff received infection control training. Some staff had received more in-depth training from an external organisation and were infection control champions in the home. These staff shared their additional knowledge with other members of the team to help minimise infection control risks and ensure correct procedures were always followed.

Rotas ensured there was a member of housekeeping staff on duty 7 days a week. Staff with housekeeping responsibilities understood their role in promoting good infection control practices. They described how they followed the national colour coding scheme for cleaning different areas of the home to reduce the risks of cross infection.

There were processes to respond to any infections in the home to mitigate the risks of them spreading.

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences.

People told us they received their medicines as prescribed. Comments included: “I do have medication and they never forget to give it to me” and “They give me my medication on time, and they never forget.”

Medicines were received, stored, administered and disposed of safely. There were processes to ensure people received their time specific or intermittent medicines as prescribed. Medicines administered via a patch applied directly to the skin were managed in accordance with manufacturers’ guidelines. Where people were prescribed medicines to be given on an ‘as required’ (PRN) basis, guidelines were in place to ensure they were given consistently and when needed. However, 1 person was prescribed a PRN medicine for distress. The medicines guidelines needed more detail to ensure all other strategies to de-escalate the person’s distress were tried prior to administration. Clinical staff assured us this would be addressed.

Staff received training in safe medicines management, and any medication errors were investigated and reflected upon.