Frome Care Village

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 the last assessment in May 2024 the service was in breach of legal regulation in relation to staffing. This assessment found improvements had been made, and the provider was no longer in breach of this regulation. At that assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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.

Staff understood their responsibilities and were clear about how to escalate concerns. There was evidence of reflective practice during supervision, and staff described learning from incidents and audits. For example, mattress setting errors were addressed through team communication and reflective supervision. The provider monitored trends in accidents and incidents and shared learning through meetings and new QR code systems they had implemented (A QR code is a specific barcode that staff can scan and add information. For example, staff scan the relevant QR code and record a medicine fridge temperature reading, which can be monitored remotely). Staff said the culture had improved significantly under the new registered manager, with open communication and supportive leadership.

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 safe admissions and transfers. Pre-admission assessments were completed, and staff confirmed they used checklists for new admissions and hospital readmissions. Individual risks were assessed promptly, including Waterlow (skin integrity assessment) and MUST (malnutrition assessment) scores, and care plans were updated.

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 procedures and were clear about how to report concerns internally and externally. They described escalating issues to managers and, if necessary, to the local authority or CQC. Training records showed staff had completed safeguarding training, and new staff were inducted on safeguarding responsibilities.

People and relatives told us they felt safe, and professionals confirmed they had no safeguarding concerns. There were no reports of unkind treatment, and staff promoted dignity and respect during care.

Where people were deprived of their liberty for care or treatment purposes, legal authorisations had been sought through the Deprivation of Liberty Safeguards (DoLS). The registered manager, maintained oversight of all applications, authorisations, and associated conditions, ensuring that all documentation remained accurate and up to date.

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.

Risks were assessed and documented, and staff involved people and relatives in care planning at admission. However, records did not always show ongoing involvement in reviews. The registered manager told us that reviews had taken place as part of a funding review for people but had not always been recorded. They confirmed they would ensure future reviews were documented.

Best interest decisions were recorded for specific interventions, such as pressure mats and vaccinations. People told us they could make choices about daily routines, and staff respected these. Relatives confirmed they were informed of changes, and staff explained risks in a way people could understand.

People had personal emergency evacuation plans in place. Environmental risk assessments were completed when areas were repurposed during refurbishment. Medicines audits and medicine administration record (MAR) checks were carried out daily, and covert medicine protocols were signed by GPs and pharmacists.

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 environment was clean and well maintained. Fire safety checks and maintenance logs were in place. Water temperatures were within safe limits, and window restrictors were fitted and regularly checked.

Refurbishment work undertaken was risk assessed to keep people safe. The provider had improved systems for recording and monitoring environmental checks using QR codes. Where IPC concerns were noted in kitchen audits, actions were taken.

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.

Consistent staffing levels on the Woodlands unit had improved since our last assessment, and call bells were answered promptly during our visits. Recruitment was safe, with DBS checks and references in place. Staff files showed evidence of induction and training, although some gaps in supervision and appraisal were noted. The provider had an action plan to address these. Staff spoke positively about support from managers and said they felt confident and safe in their roles.

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 home was clean on both site visit days, and staff had access to personal protective equipment. Laundry systems separated clean and soiled items, and cleaning schedules were in place. Staff had completed infection control training, and audits identified issues such as broken seals and missing soap dispensers, which the provider had addressed. Professionals and relatives confirmed they found the home clean and had no infection control concerns.

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.

Medicines were managed safely. Handwritten medicine administration charts (MAR charts) were double signed, and medicines requiring extra security were stored securely with weekly audits undertaken. Nurses completed daily audits of 2 MAR charts. Covert medication protocols were authorised by GPs and pharmacists. As required medicines (PRN) protocols were in place, although some required more detail. The registered manager told us they would review all protocols to ensure they had the required detail. Fridge and medicine room temperature checks were completed in line with the provider’s policy. The registered manager told us they had undertaken a review with the pharmacist supplying medicines to the home and people’s GPs to ensure people received the medicines they needed.