Clayton House

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 service under the new provider. This key question has been rated 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.

Accidents, incidents, and complaints were managed effectively, with investigations undertaken where appropriate. Lessons learned were shared with staff and used to support practice development and drive continuous service improvements.

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 provider understood the importance of accurate information sharing to ensure people’s care was joined up and safe. Systems and processes were in place to support safe transition into and out of the service. The provider worked effectively in partnership with other agencies, such as the local authority, to support this process.

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 abuse. Systems and processes supported the timely identification, monitoring, and management of safeguarding concerns. Concerns were reported without delay to the appropriate agencies, such as the Local Authority and CQC. Staff had participated in safeguarding training.

The service was working within the legal framework of the Mental Capacity Act (MCA). Where people were unable to express their wishes, relatives or representatives were consulted to support best interest decision making. Where people were subject to Deprivation of Liberty safeguards (DoLS) the provider had made applications to the local authority and there was monitoring in place. 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 registered manager took immediate action in relation to a minor issue relating to recording of 2 people’s DoLS conditions.

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 to people’s health and safety were effectively assessed, monitored and mitigated. Care records were up to date and accurate. People and relatives felt staff understood their needs and managed risks safely. They were given the opportunity to be involved in care reviews. Comments included, “They understand my needs” and “They do discuss [Name]’s plan of care with me.”

Through their quality assurance processes the provider had identified areas requiring further improvement. Progress had already been made and there were clear plans in place to fully address issues identified in relation to more detailed care planning and management of skin integrity.

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 safe and comfortable for people to live in. There was an ongoing redecoration programme in place, with significant environmental changes having already been undertaken. Areas that had been completed were designed and decorated to a high standard, providing a welcoming and homely environment. Areas and bedrooms that required improvement were already on the programme for redecoration.

Appropriate health, safety and equipment checks were in place. Equipment was clean, appropriately maintained and available for people who needed it.

Accurate personal emergency evacuation plans were in place to support the safe evacuation of people in the event of a fire.

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, who worked effectively together, to meet people’s needs without delay. They participated in training relevant to their role to support safe care delivery. The provider and registered manager maintained effective oversight of practice and ensured that any identified gaps in knowledge or areas of concern were promptly addressed through appropriate training and support for staff.

Systems and processes were in place to support safe recruitment of staff. There was a process of induction for new staff and supervision sessions were facilitated for all.

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 service was clean, tidy and odour free. Domestic staff were visible, completing cleaning duties throughout the service. Personal Protective Equipment (PPE) was readily available for staff to use when needed.

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 stored securely, and all stock levels were correct. Temperature monitoring was completed daily to ensure medicines were stored within the appropriate environmental conditions and remained safe for use. Minimum and maximum fridge temperatures were not routinely documented but the provider assured us this would be implemented immediately.

People prescribed topical creams had body maps in place to ensure staff would know where to apply these appropriately.

People prescribed 'as required' (PRN) medicines had clear protocols in place to support staff in determining when these medicines should be administered.

Controlled drugs, which require extra storage and documentation due to their potential for misuse and abuse, were checked weekly. All stock balances checked were correct with 2 staff signatures present for doses administered.

Regular medicines audits were carried out, including an external pharmacy audit. Staff followed appropriate procedures in the event of a medicine error or incident taking place. All medicines competencies for staff who handled and administered medicines within the service were up to date.