The Callywhite Care 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 remained as good.

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.

Incidents and accidents were recorded effectively by staff. These were then reviewed by leaders to identify themes, trends and areas for improvement. The registered manager explained how incidents and accidents were analysed on a monthly basis, where findings were shared with staff to promote learning across the service. Following incidents, care plans were reviewed and updated where required, and lessons learned exercises were completed to reduce the risk of similar events occurring in the future.

The registered manager told us they attended all staff handovers to ensure incidents and accidents were recorded accurately and ensure any learning was effectively communicated to staff. This supported a consistent approach to learning and continuous improvement. Staff we spoke with demonstrated a clear understanding of their responsibilities for reporting incidents and accidents and were able to describe the processes they would follow.

People and their relatives told us they knew how to raise concerns about safety and felt confident that these would be listened to and acted upon promptly.

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.

Robust pre-admission assessments were completed before people moved into the service, helping to ensure they could meet their individual needs safely and effectively. The registered manager told us they personally carried out all pre-assessments, gathering detailed information about people's health, care and support needs. This information was uploaded to the service's electronic care planning system, enabling care plans and risk assessments to be developed in a timely manner before care commenced. This ensured staff had access to accurate and person-centred information from the outset, supporting safe and consistent care delivery.

People and their relatives spoke positively about the referral and admission process. They told us communication was clear and that they felt involved in planning their loved one's care and support. This helped to ensure people's preferences, needs and wishes were understood and reflected in their care from the beginning of their journey with the service.

Relatives also described the positive support provided during people's transition into the service. One relative told us, "They introduced [family member] to people and encouraged her to make friends, they made [family member] very welcome."

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.

During our inspection, we observed people were relaxed, comfortable and at ease in the presence of staff. Staff interactions were kind, respectful and demonstrated an understanding of people's individual needs and preferences.

Staff had a good understanding of safeguarding and were able to describe the signs and indicators of abuse. They told us they felt confident in recognising and reporting any concerns and understood the escalation processes in place to protect people from harm. Staff were also aware of the provider's whistleblowing procedures, and we reviewed this being regularly discussed during team meetings, helping to promote an open and transparent culture where concerns could be raised without fear of repercussions.

The provider had effective systems and processes in place to identify, report, investigate and analyse safeguarding concerns. This supported the service to respond appropriately to concerns, identify any patterns or trends and take action to reduce future risks. The registered manager demonstrated a proactive approach to maintaining people's safety and told us they carried out regular walk rounds throughout the service to monitor standards and identify any potential concerns at an early stage.

People and their relatives consistently told us they felt the service was a safe place to live and knew how to raise concerns if needed. One relative explained, "We would be able to talk to the manager, their door is always open or if they were not there, I would speak to one of the seniors."

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes/hospitals, 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 found that where people were subject to a deprivation of liberty, the provider had implemented appropriate safeguards and processes.

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.

Risk assessments were person-centred, proportionate and regularly reviewed to reflect people's current needs and circumstances. Records demonstrated risks had been clearly identified, with detailed guidance and strategies in place to support staff to provide safe, consistent and effective care. This helped to ensure people received support that balanced their safety with their right to make choices and maintain independence.

Where risks had been identified, the provider had implemented appropriate measures to reduce the likelihood of harm. For example, sensor mats were in place for people who were at risk of falls. Relatives told us staff understood their loved ones' risks and knew how to support them appropriately, providing reassurance that care was delivered safely and consistently.

The service worked in partnership with people and those important to them when making decisions about risk management. Relatives told us they were actively involved in discussions about their loved ones' safety and were consulted before changes were made to their care and support. One relative said, "We have made any decisions together along the way, about [family members] falls and how to keep [family member] safe. If they do something they let us know and if we don't agree we may suggest another option."

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

The home was spacious and easy to navigate, with large open-plan communal areas that had access to outdoor garden space. The premises were secure, and systems were in place to ensure only authorised individuals could access the building.

Appropriate procedures were in place to alert staff if people entered other people's bedrooms, supporting their safety and wellbeing. At the same time, people were able to lock their bedroom doors if they wished, promoting privacy, dignity and choice.

The provider had effective arrangements in place to maintain a safe environment. Regular health and safety checks were completed, and the maintenance team demonstrated robust systems for monitoring and addressing environmental risks. Records showed these checks were undertaken consistently and were overseen by the registered manager.

Staff received appropriate health and safety training, including fire safety and health and safety awareness.

People and their relatives spoke positively about the upkeep of the home and told us any environmental issues were addressed promptly.

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.

There were enough staff available to meet people's needs promptly and safely. Staff responded to requests for support in a timely manner, and people appeared comfortable and reassured by the presence of staff throughout the home.

The provider had safe recruitment processes in place. Recruitment and staff files were maintained and contained the necessary information to support safe employment practices.

Staff were provided with the training and support they needed to carry out their roles effectively. Training records showed staff completed mandatory training in a timely manner, and the provider maintained good oversight of training compliance. The service was compliant with the mandatory training requirements relating to learning disability and autism, helping to ensure staff had the knowledge and skills to provide person-centred care and support.

Where people had specific needs, staff received additional specialist training to enable them to provide safe and effective care. For example, staff had completed training in epilepsy, and positive behavioural support. This meant staff were equipped with the skills and understanding required to support people with a range of health conditions and individual 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.

The premises and equipment were clean, well maintained and hygienic. Communal areas, bathrooms, bedrooms and equipment appeared visibly clean, helping to provide a safe and comfortable environment for people living at the service.

The service had suitable facilities to support effective infection prevention and control practices. This included access to dedicated handwashing facilities, a sluice room, appropriate laundry arrangements and safe waste disposal systems. These facilities supported staff to manage infection risks safely and in line with current guidance.

We observed staff following good practice, including effective hand hygiene and the appropriate use of personal protective equipment (PPE) when required. Staff receivedInfection, prevention and control (IPC) training, which helped ensure they had the knowledge and skills needed to keep people safe from avoidable infection risks.

The provider maintained oversight of infection prevention and control through regular IPC audits, enabling them to identify and address any issues promptly. In addition, up-to-date IPC policies and procedures were available to staff, providing clear guidance on best practice and expected standards.

The provider had systems in place to safely store, administer and record the use of medicines. The service did not have individual fire risk assessments in place for people who were prescribed paraffin-based skin products. The use of topical creams and ointments were recorded on the electronic medicines administration records (eMARs). Body maps were in place to show staff the site of application.

Documentation was not always available to support staff to give people their medicines according to their preferences. We checked the quantities and stock balances for 8 people and found some of them to be incorrect. This meant we could not be sure people had received their medicines as prescribed. Instructions for medicines which should be given at specific times were not available.

Thickeners used to thicken fluids for people with swallowing problems were recorded when they had been used. Some people were prescribed a medicine administered via a patch which needs rotating to different areas of the body, as recommended by the manufacturer. There was a process in place to indicate the site of application to prevent the patch being placed on the same site too frequently.

Detailed guidance specific to each person on how to administer medicines prescribed as and when people required them, known as “PRN” was available to staff. When there was an option to give a variable dose, the actual dose given was recorded.

Two people were being given their medicines covertly (disguised in food or drink). Appropriate assessments had been undertaken, and documentation was in place to ensure these were given appropriately and safely. Liquid medicines had the date of opening recorded on their labels, which reduces the risk that medicines could be administered beyond their once‑opened expiry date.

There were appropriate arrangements in place for the management of controlled drugs and staff completed regular balance checks. Temperature records to ensure the safe storage of medicines were not completed in accordance with national guidance.

There was evidence that there was a process in place to record medicines related incidents or errors. Staff told us they had completed a training and induction process for medicines management. Staff competencies were assessed regularly to make sure they had the necessary skills.

Managers and members of staff qualified to handle medicines regularly completed audits (checks) to make sure that procedures were followed. However, the problems found during our inspection had not been previously identified.